ML20151N506
| ML20151N506 | |
| Person / Time | |
|---|---|
| Site: | Beaver Valley |
| Issue date: | 04/13/1988 |
| From: | Bissett P, Dudley N, Eselgroth P NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20151N483 | List: |
| References | |
| 50-334-88-02, 50-334-88-2, NUDOCS 8804250315 | |
| Download: ML20151N506 (24) | |
See also: IR 05000334/1988002
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U.S. NUCLEAR REGULATORY COMMISSION
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Report No.:
50-334/88-02
License No.: DPR - 66
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Licensee: Duquesne Light Company
P.O. Box 4
Shippingsport, Pennsylvania
15077
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Facility Name:
Beaver Valley Power Station, Unit 1
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Inspection at:
Shippingsport, Pennsylvania
Inspection conducted:
February 1 - 5, 1988
Inspectors:
usM
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. BissWtTSenior Operations Specialist
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N. Oudley, Hnior Operations Specialist
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Approved by:
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P. Eselgroth
hief,'FWR Operations Section
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Summary:
Routine ann unced inspection on February 1-5, 1988
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(Report No. 50-334/88-02)
Areas Inspected: A routine announced inspection was conducted in the area of
operations to review licensee conformance to the NRC approved Procedure
Generation Package regarding the development and implementation of their
Emergency Operating Procedures (E0P). Areas examined included the Administra-
tive Program; Technical Adequacy; Writer's Guide conformance; and Independent
Verification of set point values. Temporary Instruction 2515/79, Inspection of
Emergency Operating Procedures was used as inspection guidance.
Results: An apparent deviation of the licensee's commitment to follow its NRC
approved Procedures Generation Package was issued based on the numerous
problems identified during the inspection.
The technical content of the
licensee's E0P was found to be adequate.
However, a number of inconsistencies
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between the Procedures Generation Package and the E0Ps and Background
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Information documents were found in the areas examined.
The basic documents
for E0Ps were not controlled, contained errors and were inconsistent with the
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guidance contained in the Procedure Generation Package (paragraph 2.5.1).
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logic terms, branching statements, cautions and sentence structure of the steps
in the E0P did not conform to the guidance in the Procedure Generation Package
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(paragraph 2.5.3).
The nomenclature of plant components and instrumentation
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was not in accordance with the guidance contained in the Procedure Generation
Package and led to operator uncertainty, (paragraphs 2.0.4, 2.5.5 and 2.5.6).
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The human factor deficiencies in tne E0Ps appear to have been compensated for
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by the raining and experience of the operators.
8804250315 880413
ADOCK 05000334
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DETAILS'
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PERSONS CONTACTED
1.1 DUQUESNF i.IGHT COMPANY
T. Burns
DIRECTOR OPERATOR TRAINING
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R. Druga
MANAGER TECHNICAL SERVICES
L. Freeland
NUCLEAR OPERATIONS SUPERVISOR
K. Grada
MANAGER NUCLEAR SAFETY
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W. Lacey
PLANT MANAGER
F. Lipchick
SENIOR LICENSING SUPERVISOR
A. Mizia
SUPERVISOR QA OPERATIONS
A. Morabito
MANAGER NUCLEAR TRAINING
T. Noonan
ASSISTANT PLANT MANAGER
E. Schad
SIMULATOR COORDINATOR, TRAINING
F. Schaffner
LICENSING ENGINEER
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8. Sepelak
LICENSING ENGINEER
G. Smith
PROCEDURES ENGINEER
J. Russell
SENIOR QA SPECIALIST
1.2
U.S. NUCLEAR REGULATORY COMMISSION
J. Beall, Senior Resident Inspector
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S. Pindale, Resident Inspector
The inspectors also interviewed other licensee personnel during the
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inspection period.
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- Denotes those present at the exit meeting conducted on February 5,
1988.
2.0 EMERGENCY OPERATING PROCEDURES
The purpose of this inspection was to verify that Duquesne Light Company's
Emergency Operating Procedures (EOPs) were written, verified and validated
in accordance with the licensee's NRC approved Procedures Generation
Package and training was conducted on the use of the procedures.
2.1 REGULATORY REQUIREMENTS / REFERENCES
Regulatory Guide 1.33, Rev. 2 - February 1978, Quality
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Assurance Program Requirements (Operations).
ANSI N18.7-1976, Administrative Controls and Quality
Assurance for the Operational Phase of Nuclear Power
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Plants,
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Westinghouse Owners Group (WOG) - Emergency Response
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Guidelines (ERG) - High Pressure Version, Rev.1,
September 1983.
Generic Letter 82-33, Supplement I to NUREG-0737, -
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Requirements for Emergency Response Capability.
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NUREG-0899, Guidelines for the Preparation of Emergency
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Operating Procedures.
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Technical Specific ~ations.
Emergency Operating' Procedures Generation Package,
Revision 1, April 1987.
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2.2 PROGRAM REVIEW
The licensee's program for preparation of E0Ps was reviewed to verify
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that:
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The licensee has developed a Procedure Generation Package which
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includes Plant Specific Technical Guidelines, a Plant Specific
Writers Guide, a description of the program used for verifying
and validating the licensee's E0Ps, and a description of the
program for training operators on E0Ps.
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The licensee has developed Emergency Operating Procedures
(EOPs) consistent with the guidance of Duquesne Light Company's
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and NUREG-0899.
The E0Ps use a consistent format, which was easy to follow and
was as defined in their PGP.
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The operators have been trained to use the E0Ps and the E0Ps
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were useable.
Differences between Westinghouse's Generic Guidelines and the
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licensee's specific E0Ps were identified and justifiad.
The licensee had an administrative program for developing the
E0Ps and controlling changes to them.
The E0Ps were technically adequate and capable of placing the
plant in a safo condition following a reactor trip or actuation
of the safety injection system.
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2.3 PROGRAM IMPLFMENTATION
Procedures listed in Attachment A were reviewed by the inspectors against
the requirements and committents of paragraph 2.1.
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2.3.1
ADMINISTRATIVE PROGRAM
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The inspectors reviewed the program for controlling Operating
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Manual Deficiencies Reports (OMOR) for the E0Ps to ascertain
whether proper controls were being exercised,
Several 0MORs
were reviewed and the following items verified:
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An adequate description of the procedural change.
An adequate description of the reason for the change.
Documentation of required authorization.
The Onsite Safety Committee review and approval of the
change.
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Proper final disposition of each change.
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2.3.2
TECHNICAL ADEQUA,CY
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The inspectors compared seven E0Ps against the ERGS and also
performed concurrent evaluations of the technical adequacy of the
E0Ps.
During this review, the E0Ps were reviewed for consistency
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with the ERGS, against the step-by-step verification documenta-
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tion and against the documentation which justified those steps
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which deviated from the ERGS.
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2.3.3
HUMAN FACTORS
Five E0Ps were reviewed to determine the extent to which they
followed the format and content instructions committed to in
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the Dr oesne Light Company Writer's Guide and whether they met
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the objectives found in NUREG 0899.
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2.3.4
VALIDATION / VERIFICATION PROGRAM
Inspectors reviewed sample documentation of the
validation / verification program for adequacy and verified the
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procedures during plant walk through and simulator scenarios,
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2.3.5
WALK THROUGH
Inspectors conducted a walkthrough of two E0Ps in the main
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control room. Comparisons were made between the E0Ps and
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control room main panels, and between valve lineups contained
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in the Attachments to the E0Ps and components outside the main
control room, to determine whether:
The controls / displays identified in the E0Ps as being in the
control room were there;
The control / display nomenclature used in the E0Ps was
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comparable to that found in the control room;
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The control / display to be used to complete a step were
clearly defined;
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The components required to be checked outside the main
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control room were accessible and clearly. marked; and,
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The displays could be read to the accuracy required by the E0Ps.
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2.3.6 SIMULATOR
An exercise of the E0Ps was conducted on the Beaver Valley
Unit 1 simulator. The exercise objectives were:
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Tc determine whether the E0Ps are usable for the level
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of qualifications, training and experience of the
operating staff, and
To determine whether the E0Ps are compatible with the
minimum number of operating staff.
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Three simulator exercises were developed to cover the subset of
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the E0Ps that had been reviewed for the audit.
The exercises
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included:
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Stuck open PORV which is later SHUT; Multiple instrument
failures
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Loss of ALL AC Power
Restoration of one Emergency Bus
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All Steam Generators faulted
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The scenarios were chosen because they exercised a large
portion of the E0Ps under review, and they covered a variety of
emergency situations.
The scenarios were developed to evaluate the
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use of instrumentation, the use of branching statements and the
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use of the critical function status trees.
2.4 OA/QC INVOLVEMENT
The inspectors contacted Quality Assurance (QA) personnel in order to
determine what role QA had in the development and validation of the E0Ps.
QA management stated that their involvement to date included a review in
March 1987 of the licensee's Procedure Generation Package (PGP) against
IE Information Notice 86-64 and Appendix B of NUREG 0899,
The inspectors
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reviewed QAs written comments following this review and the subsequent
resolution to these comments as provided by the Procedures Group.
The QA
Supervisor stated that they had not yet performed any audits of the E0P
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program or the E0Ps themselves, however both areas are considered audit-
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able items under the QA program.
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2.5 FINDINGS
2.5.1 ADMINISTRATIVE PROGRAM
Portions of the licensee's procedural change program for E0Ps were
reviewed.
The Nuclear Operation Supervisor (N05) is responsible for
approving all discrepancies prior to their incorporation into the E0Ps in
accordance with the Procedure Generation Package, paragraph VI.C.1.g.
All
deviations from and additions to the Westinghouse Owner's Group Emergency
Response Guidelines (ERG) are required to be documented on E0P-ERG
Deviation forms in accordance with paragraph VI.B.1.f.
No temporary
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changes to the E0Ps are allowed, and therefore, any procedural changes
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will result in a complete reissue of the affected E0P.
The licensee has a formal program for in'tiating changes to the E0Ps by
using Operating Manual Deficiency Reports (0MDR).
The OMDRs are reviewed
by the NOS prior to being given to the E0P writer for resolution. The
OMDRs are tracked on a computerized system..There is no formal program for
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disposition of the OMDRs once they are reviewed by the N05. There is no
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supervisory review of the completed OMDRs or modified E0P-ERG Deviation
fo rms. Only the E0P changes resulting from an OMDR are reviewed by
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supervisory personnel.
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A review of the completed E0P-ERG Deviation forms by the inspectors
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identified technical errors.
In one case a set point was lined through
and a new set point written in.
There was no initial or date for the line
out and the new set point did not correspond to the set point in the E0Ps.
In a second case no E0P-ERG Deviation form existed for E-0 step 29, even
though deviation forms existed for similar steps. All E0P-ERG Deviation
forms are hand written with numerous line outs of technical information
and justifications without explanation or apparent systematic controls.
Changes made to the E0Ps as a result of one Onsite Safety Committee (OSC)
meeting were not documented on the E0P-ERG Deviation forms.
The E0P-ERG Deviation forms did not contain sufficient detail to fully
explain the technical reasons for deviations.
In one case, the E0P writer
needed to call the training department in order to explain the intent and
basis for changing E-0 step 1.
In a second case, a high head safety
injection pump was secured without a documented engineering basis,
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Portions of the licensee's Background Information for E0Ps was reviewed.
The background information package for each E0P provides information on
the event symptoms, entry conditions, exit conditions and recovery
techniques used in each E0P.
In addition the purpose, basis, actions,
instrumentation, control equipment, knowledge and technical references for
procedural step are provided in Step Description Tables.
The majority of
indications presented in the Step Description Tables do not ir.clude the
benchboard identification of the instruments to be used as required in
the Procedure Generation Package Appendix B Section IV.A 4.e.
Examples of
indications which were not defined by benchboard identification include
total AFW flow and component cooling flow to RCPs. Many Step Description
Tables did not provide technical references as required by the Procedure
Generation Pr.ckage Appendix B Section IV.A.4.e.
Failurs to include the benchboard identification of the instruments to be
used in the Step Description Tables as required by the Procedures
Generation Package is a part of the deviation identified in paragraph
2.5.7 below.
As part of the review of the E0P-ERG deviation forms, a technical error
was identified in the Procedure Generation Package Section 5, paragraph
11. The paragraph states that the Beaver Valley Unit I component cooling
water (CCW) system is essentially identical to the CCW system of the
reference plant, which is without an appropriate technical basis.
The CCW
system of the reference plant cools four components; the RHR heat
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exchanger, the seal water heat exchanger, the containment fan coolers and
the reactor coolant pumps.
However, the CCW system at Beaver Valley Unit
I does not cool the RHR heat exchangers nor containment fan coolers, whica
result in differences between steps in the E0P and in the ERG.
Review of
Section 5 of the Procedures Generation Package is needed to ensure there
are no other technical errors.
2.5.2 TECHNICAL ADEQUACY
The E0Ps compare well technically with the ERGS. Minor discrepancies were
found that were needed to compensate for the specific plant design and/or
the technical specifications. Many instances were noted where additional
steps were added over and above what was called for in the ERG.
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majority of these additional steps were to provide further clarification
and direction to the operators.
E0P-ERG Deviation forms were generated
as necessary, however as stated in paragraph 2.5.1, many forms did not
contain sufficient detail to fully explain the technical basis for
deviations.
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In one instance the licensee deviated from a directive in the ERGS and did
not provide a written technical justification for the deviation.
The ERGS
require that additional steps for verification of other essential equip-
ment as required by the specific plant design, should be placed after E-0
step 12. The facility's E0Ps ccntain seven additional steps prior to E-0
step 12 of the ERGS and no E0P-ERG Deviation form has been written.
The
licensee stated that the EDPs contained the additional steps because the
supersedea event based reactor trip procedure contained the same step
sequences and in order to minimize the amount of operator retraining
required to implement the new E0Ps, the steps of the superseded trip
procedures were retained.
Training concerns are not considered to be a
sufficient technical basis for deviating from the ERGS.
A problem was noted during the review of ECA 0.0, "Loss of all AC Power."
Several actions, such as operation of valves and pumps, are required
during the time period when attempts are being made to restore AC emer-
gency oower to these components.
Many of these steps will be impossible
to couplete as long as power is unavailable.
ECA 0.0 requires further
review to ensure that power would be available to all components which are
required to be coerated.
2.5.3
HUMAN FACTORS
The human factors review involved a comparison of the E0P with the
Writer's Guide and with NUREG 0899. Discrepancies were grouped into five
main areas. A summary of the major issues for each of the areas is
provided beloe. Specific comments and examples of the major istues are
provided in Attachment B.
Lcgic Terms The Writer's Guide presents definitiens and format
instructions regarding the writing of conditional statements using the
logic terms. While the instructions provided were incomplete, those which
were provided were not applied correctly within the E0Ps.
Four major
areas of concern were identified:
The use of AND and OR (together and sepsrately) within action
statements.
The inappropriate structuring of IF, THEN statements.
The use of the implicit IF NOT in the Response Not Obtained (RNO)
column.
The use in the RNO column, of an IF NOT statement witnout an initial
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_ Referencing and Branching
The E0Ps contained a number of transition terms which were undefined in
the Writer's Guide and inconsistent with the guldance provided.
Notes and Cautions Cautions and Notes in the E0Ps were often misused by
their structure as directives or inclusions of inappropriate information
(i.e., non-critical information in Cautions).
Sentence Structure The E0Ps utilized inconsistent structural methods for
similar types of statements, conflicting not only with the guidance
provided in the Writer's Guide, but utilizing a number of different
structures for one type of statement within a single E0P.
In addition,
action statements included two to three directives within one step.
Miscellaneous Other problems were found in the E0Ps including
use of vague terminology and inconsistent use of abbreviations and
The licensee's failure to follow the Writer's Guide is discussed in a
deviation identified in paragraph 2.5.7.
2.5.4
VERIFICATION / VALIDATION
Verification:
The licensee's Procedure Generation Package described the
verification of the E0Ps for correctness, using the Writer's Guide as a
basis for evaluation.
The program is described as being carried out by a
team of personnel from Operations, Training and Procedures groups. A
checklist is used as a guide to the process and discrepancies are
forwarded to the EOP writer for correction. A decision is made by the NOS
whether a follow-up verification or validation of the draft E0P is needed.
Verification activities at Beaver Valley were carried out by Duquesne
Light Company personnel with assistance from a human factor consultant
during the initial verification.
A control room and plant walk through by inspectors to verify selected
E0P steps identified a number of examples where the nomenclature of
instrumentation in the E0Ps was inconsistent with the nomenclature found
in the control room and the plant.
Some examples where the nomenclature in
the E0Ps was different than that found on the name plate data are:
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E-0 Entry Conditions refers to annunciator window A5-47 "Manual
Reactor Trip From Main Control Board." The annunciator window
is now in position A5-9.
E-0, Attachment 2 refers to MOV-RW-1130 "River Water to D.G.
Heat Exch." which must be checked locally.
Due to a design
change MOV-RW-1130 has been replaced by MOV-RW-11301 which is in
a different room.
E-0 Attachment 2 refers to four valves which should be checked
locally at the Diesel Generators, as "River Water to D.G. Heat
Exch." The valves at the generator are labelled "RAW Water
Valves #1 and #2."
The licensee had identified that the nomenclature in the main
control room does not meet the requirements of the Writer's
Guide.
Subsequent observation by the inspectors of the use of the E0Ps on
the simulator indicated that the nomenclature disparity between the
E0Ps and the control room panels presented no confusion to the
operators. However, during the simulator scenarios the lack of
detailed sper.ifications of instrumentation resulted in the operators
using instrumentation which was not in accordance with the licensee's
plant specific background document.
Some examples where incorrect
instrumentation was used during the simulator scenarios are:
E-0 step 6.a. the operator used breaker position and an
annunciator window to verify an AC emergency bus was energized.
The background document requires that the voltmeter be used.
E-0 step 9.1, the operator used an annunciator to verify
the turbine-driven AFV pump running.
The background
document does not provide an instrument to check for
completing this step.
It was .he consensus of the operators
that the position of steam valves are checked for ensuring
the turbine-driven AFW pump is running.
Appendix F of the Procedure Generation Package, paragraph II. A.2.b,
requires that the E0Ps be reviewed for technical accuracy of
"Operator Instrumentation and Control Needs."
Failure to correctly
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translate control room and plant switch and indicator nomenclature
into the E0Ps as part of the verification program is a part of the
deviation Identified in paragraph 2.5.7 below,
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Validation:
The validation process is described in the licensee's
Procedure Generation Package as a demonstration that the operating
staff can manage the emergency condition through the use of the
procedures and that the E0Ps are operationally correct in respoct to
usability, technical correctness, operational correctness and
effectiveness.
The Procedure Generation Package indicates that table
top reviews, control room walk through, or simulator exercises will
be used to validate E0Ps.
The documentation for the validation of
procedure E-0 was reviewed and found to be adequate for the table top
review, simulator and control room walk through.
However , the
inspectors identified discrepancies in procedure E-0 during the plani.
walk through, as described below.
2.5.5 WALK THROUGH
The walk through of procedures in the main control room
and in the plant identified deviations of E0P procedural steps and
the recommendations in the Procedures Generation Package.
The Weiter's
Guide in paragraph V.B.g states that "identification of components
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and parts should be complete." An example of a step which did not
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satisfy this requirement is:
E-0 Symptomatic Response / Unexpected Conditions, 1 a. CRR flow to
RCP's - NO FLOW INDICATED.
The operator was uncertain what readings would be e a ptable, and the
basis document does not indicate the required ins.
..+nt.
The Writer's Guide in paragraph VI.E.1.d states that "users should
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not be required to add or subtract nembers to determine acceptable
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values." Contrary to this:
E-0 step 17, Verify Total AFW Flow - GREATER THAN 350 GPM;
requires the operator to sum the values from three flow
instruments.
E-0 step 21.a.2,a, RCS/ Highest D/P - LESS THAN 150 PSIO;
requires the operator to select the highest reading from
one of nine pressure instruments and to subtract it from
the reading of a tenth pressure instrument.
E-0 step 12. a, Steam line pressure high rate of change -
99 PSIG DECREASE IN 50 SECONDS; requires the operator to
calculate a rate of change.
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The walk through in the plant was performed to assess the acequacy of
various factors involved in the performance of ECA 0.0 "Loss of All
AC Peter." Areas reviewed which included equipment identification, acces-
sibility of equipment, and the availability of emergency lighting and-
communications equipment (dedicated Appendix R phone service line)
were found to be adequate.
Valves and breakers were for the most-
part readily accessible, with the exception of a few instances'where
temporary scaf folding was in place (e.g., IA-90).
Valves TV-CC-107E2
and 02 were difficult to access primarily because of piping confi-
guration.
Valve identification tags were considered inadequate, esptcially when
considering a loss of lighting, when a valve might have to be located
and subsequently operated.
Identification tag deficiencies, observed
by the inspector, include tags that were missing, damaged or bareac-
able. The licensee utilizes a lightweight thin metal strip embossed
wi'.h the letters / numbers of the appropriate valve.
The dimensions of
the tag are approximately 5" x 1/2" and the tag is normally attached
at one end to the valve body.
The inspector found it difficult, in a
nuber of instances, to read the 10 tag, even under normal lighting
conditions.
Valves TV-CC-107E2 and 02 are examples in which diffi-
culty was experienced in reading the valve identification tag
numbers.
The 10 tags had to be "in-hand" in order to accurately read
them.
The readability of the 10 tags presently in use is question-
able. Other examples of 10 tag discrepancies include:
1 MOV-IN-1558 - 10 tag missing
1 MOV-IN-ISSA - 10 tag damaged
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MSIVs vent panel valves - 10 tags missing
1 MOV- N-151 volves - 10 ;ags missing or damaged
Dedicated A W pump valves - missing 10 tags
The licensee >tated that efforte have been underway to ensure that tag ids
are accurate ar.d in place, h: wever it is an ongoing program. Those areas
where pump, valve and breaker manipulations might be called for under loss
of lighting conditions require escalatt.d action.
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2.5.6 SIMULATOR
No procedural deficiencies were observed during the simulator portion
of the audit.
Problems identified during the walk through were con-
firmed in observations and discussions with the operators in-the
simulator. Operator actions were taken in accordance with the-
E0Ps.
However, the requirements contained in the ERG Users Guide
were not followed during the development of the E0Ps.
For. example:
E-0 step 1, the operator transitions to FR-S.1 prior to
checking reactor power decreasing.
The ERG requires that power
be checked prior to the transition.
E-0 step 6.a, the operator reported power to the AC Emergency
Bus even though the voltmeter indicated zero volts.
The ERG
requires the use of the voltmeter.
E-0 step 24, the operator diu not check the containment
sump level recorder as required by the basis document.
Operator actions were slowed due to the wording of some procedural
steps.
ECA 0.0 step 32.a contained an "AND/0R" step which t'ne
operator had to reread several times before proceeding.
The operator
experienced difficulty determining subcooling margin requirements
prior to transitioning out of ECA 0.0 "Loss of All AC Power," and
finally referred to a pressure temperature graph which was not part.
of the E0Ps.
From observations of operators in the simulator and
from discussions with the licensee, deficiencies identified in the
wording, structure and format of the procedural steps appear to have
been compensated for by operator training and experience instead of
rewriting the steps to correspond to the Writer's Guide,
f
2.5.7
SUMMARY
The technical content of the licensee's E0Ps was reviewed in detail
and determined to be consistent with the Westinghouse Owners Group
Emergency Response Guidelines and the licensee's Procedure Generation
Package. A human factors review of the Writer's Guida, revealed
numerous deficiencies including, but not limited to the incorrect and
i
inconsistent use of logic statements in the E0Ps. The documentation
of the deviations identified by the validation program was found to
be deficient. The basis document for the E0Ps do not include
detailed instrument specifications nor references in accordance with
the Procedures Generation Package. The verification program failed
to correctly translate control room and plant switch and indicator
nomenclature into the E0Ps.
. . .
,
.-
14
-
There has been no human factors or quality assurance involvement in
the validation of the latest revision of the E0Ps. Numerous human
factors issues, related to the Writer's Guide, and numerous
deficiencies identified in the E0P-ERG Deviation Forms and the
Background Information documents indicate deviations from the
Procedures Generation Package.
Based upon the above and the detailed
discussions in paragraph 2.5.1, 2.5.3, 2.5.4, 2.5.5, and Attachment
B, this is an apparent deviation of the licensee's commitment to
follow the NRC approved Procedures Generation Package
(50-334/88-02-01).
3. INDEPENDENT VERIFICATION
The inspectors independently verified that various levels and values given
in the E0Ps were consistent with the indicators found in the control room
and that the operators were knowledgeable of where various switches were
located. The inspectors reviewed the documentation of five plant specifi'c
setpoints and determined that the engineering analysis to support the
plant specific setpoints were not referenced in all cases.
This failure
to reference supporting documentation contributed to the apparent
deviation summarized in paragraph 2.5.7.
4.
EXIT INTERVIEW
l
An exit meeting was held February 5, 1988, to discuss the inspection scope
and findings, as detailed in this report (see paragraph 1.0 for
attendees).
At no time was written material given to the licensee.
The inspector
determined that no proprietary information was utilized during the
inspection.
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ATTACHMENT A
DUQUESNE LIGHT COMPANY, BEAVER VALLEY UNIT 1, PROCEDURES REVIEW
E-0
Reactor Trip or Safety Injection, Issue 1, Rev. 1
E-3
Steam Generator Tube Rupture, Issue 1, Rev. 1
SI Termination, Issue 1, Rev.1
SGTR With Loss of Reactor Coolant - Subcooled Recovery
Desired ECA - 3.1, Issue 1, Rev. 1
ECA 0.0
Loss af All AC Power, Issue 1, Rev. 1
J
ECA 0.1
Loss of All AC Power Recovery Without SI Required, Issue 1,
Rev. 1
ECA 2.1
Uncontrolled Depressurization of All Steam Generators,
Issue 1, Rev. 1
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4
ATTACHMENT B
REVIEW 0F WRITER'S GUIDE
1.
The Writer's Guide,Section V.E., presents definitions and format
instructions regarding the writing of conditional statements using logic
terms. The instructions provided are not applied consistently within the
E0Ps. The following problem areas were identified,
a.
When used as conjunctions, "and" and "or" join lists, multiple
actions or alternatives. When used as logic terms, they indicate
decision points.
It is important that appropriate emphasis be used
when these words are being used in a conditional statement, to signal
to the operator that a decision point has been reached. When used to
indicate multiple actions, alternatives or a list, "and" and "or"
should not be emphasized as logic terms.
The Writer's Guide does not
provide explicit direction on the different use and formatting of
"and" and "or".
The E0Ps contain different types of formatting for
these words which are not consistent with the Writer's Guide.
Example:
E-0, step 25.b and c.
25.b.
Secondary heat sink:
,
Total feed flow to intact SGs - GREATER THAN 300 GPM
- OR -
Narrow range level in at least one intact SG -
GREATER THAN 57.
25.c.
RCS pressure - STABLE OR INCREASING
This step uses the conjunction "or" in two different formats.
Because
"or" is functioning as a conjunction in both uses, it should be formatted
consistently. While the Writer's Guide lacks format information for the
use of "or" as a conjunction, neither use of "or" within the above step is
consistent with the guidance provided in Section V.E of the' Writer's
i
Guide for the emphasis of the logic term OR.
- -
. - - _ _ _
_, ._.
_ _ . _ . _ . , _ .
- _. _ _ . , _ .
..,
- . _ . _ - - - _ . . . - . . , - . .
-
-
,
.
.-
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__
--
_.
_ ..
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...
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Attachment B
2
.
.
Other examples of this type of problem found in the E0Ps
sampled include:
E0P
STEP
PROBLEMS
E-0
35
-or-
E-0
36.b
-AND-
2 RNO
AND (not a conditional statement)
E-0
13. a
and
E-0
3 RNO
or
E-0
13.a
-or-
E-0
13.b RNO ANO (not a conditional statement)
E-0
22.a RNO and (a conditional statement)
b.
The Writer's Guide provides direction on the use of the logic
sequence IF, THEN in paragraph V.E.
There are a number of IF NOT, THEN statements which-are not
formatted consistently with the guidance provided.
P
Example:
'
E-0 Step 7 RNO
Check if SI is required:
...
IF SI required, THEN manually actuate.
'
IF SI is NOT required, THEN GO TO ES-0.1,
i
WReactor Trip Response," Step 1.
'
This step conflicts with the format directions in the Writer's
Guide, which indicates that the term IF NOT will not be split.
Other examples of this problem found in the E0Ps sampled include:
E0P
STEP
E-0
6.a RNO
i
9.f RNO
20.a RNO
j
>
20.b RNO
Example:
<
ECA-0.0 step 7.a.3
RNO
Verify proper emergency alignment of AFW valves.
IF NOT properly aligned,
THEN manually align AFW valves [MOV-FW-151A-F] as necessary
The step does not contain the first conditional IF.
.
.
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.
.
.
.
.
.
.
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,
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_
.
Attachment B
3
.
Other examples of this type of problem found in E0Ps sampled include:
E0P
STEP
E-0
13.a.1 RNO
E-0
13.a.2 RNO
E-3
21.a.2 RNO
ECA-0.0
20.c
RNO
ECA-0.0
21.b
RNO
ECA-0.0
33.a
RNO
ECA-1.1
13.f
RNO
ECA-2.1
15.b.2 RNO
c.
The two column format used in the E0Ps is structured so that
the right hand column includes an implicit "if not" relation-
ship to the left hand column.
In a number of statements in the
E0Ps, the "if not" has been repeated in the right hand column,
unnecessarily cluttering and complicating the procedure, and not
taking advantage of the RNO structure.
Examples:
)
E-0 step 4.b RNO
)
IF reheater flow control block valves will NOT close, THEN
manually close main steam line trip, bypass and non-return
valves.
E-0 step 11.a RNO
a. IF CIA has NOT actuated
THEN manually actuate CIA
-0R-
Manually align CIA valves
Other examples of this type of problem found in the E0Ps
sampled include:
E0P
STEP
E-0
12.b RNO
E-0
23.d
E-0
23.d RNO
E-0
25.b RNO
9
RNO
11
RNO
E-3
17.d RNO
E-3
23.b RNO
E-3
26
ECA-0.0
14
RNO
ECA-0.0
24
RNO
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Attachment B
4
2.
The Writer's Gu'ide Section V.H. 2. defines "go to" as the transition term
'l
to be used within the E0Ps and provides format instructions. The EOPs,
however, use a number of different' terms to indicate movement within and-
between E0Ps. The Writer's Guide does not define the minimum number of
terms necessary for clear instruction to operators on transitions.
Examples:
E-0,
Step 23 RNO
GO TO E-3 "Steam Generator Tube Rupture," Step 1 AND in.
conjunction complete only Steps 23b through 23d.
,
This step contains two transition terms which is not in accordance with
the Writer's Guide and one of the terms is not defined in the Writer's
'
Guide.
Step 15 RNO
1
a.
WHEN PRZR level greater than 18% THEN perform Step 16.
Other examples of this type of problem four.d in the E0Ps
sampled:
E0P
STEP
TRANSITION TERM OSED
1
27.a RNO
"do"
E-3
3
RNO
"do"
'
E-3
30.b RNO
"do"
ECA-0.0
18
RNO
"perform"
ECA-0.0
16.b RNO
"do"
ECA-0.0
26.a RNO
"G0 TO...THEN do"
ECA-2.1
7.f.2 RNO
"do"
3.
Cautions are used to describe a hazardous condition which can cause
injury or equipment damage and should describe the consequences of the
hazard. Notes are intended to provide supplemental information to the
operator.
Neither Cautions nor Notes are to include action statements.
The human factors review revealed several problem areas related to
Cautions and Notes:
Caution (s) and Note (s) in the E0Ps sampled were found to contain
,
directives and references which are action statements.
Some Cautions lack
-
a statement of the hazard at hand and possible consequences.
Following
are instances of improper use and structure of Caution (s) and Note (s):
.
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Attachment B
5
E-0, page 23
CAUTION:
RCS pressure should be monitored.
If RCS
pressure decreases to less than 250 PSIG, the LHSI
pumps must be manually restarted to supply water to
the RCS.
This Caution lacks identification of the hazard and consequences
related to a low RCS pressure.
The Caution also contains a
directive which more appropriately is an action statement.
Other examples of these types of problems found in the E0Ps
sampled include:
E0P
PAGE
PROBLEM
E-0
13
Note contains action statement.
E-0
14
Note contains action statement.
10
Caution lacks identification of the
consequences of the hazard. Caution
contains action statements.
i
E-3
7
Caution lacks identification of hazard
or consequence.
E-3
7
Caution contains branching statements.
E-3
14
Caution contains logic statement.
Caution lacks identification of hazard
or consequence.
E-3
30
Caution lacks identification of
i
consequence.
ECA 0.0
17
Note contains action statement,
f
ECA 0.1
16
Caution contains logic statement.
4.
Sentence structure is an important factor in the presentation of clear
and understandable instructions.
The inspector's review identified several
problem areas related to sentence structure in the E0Ps.
a.
The Writer's Guide, paragraph V.B.1 indicates that steps are to
be written concisely, describing .just the task to be performed and
that complex evolutions are to be broken down.
The following step
includes more than one action:
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- Attachment B
6
.
E-3.1
step 5.C
Trend RCS temperature and pressure on the main
computer at 10 minute intervals.
Initial the trend
every half hour to ensure that-cooldown does not
exceed 100F/hr in RCS cold legs.
Other examples of these type of problems found in the E0Ps
sampled include:
E0P
STEP
ECA-0.0
11
ECA-0.0
26.b RNO
2
5.b.3
22.a
ES-3'.1
5.e
9.b
9.e
11.a
33
35 b.3
b.
A system of step numbering and identification can assist the operator
j
in moving through procedures without confusion.
The review of the
E0Ps revealed an inconsistency in the use of bullets which indicate
no preferred order of completing action s ;eps.
In some steps where a
check is made of multiple indications, bullets are used, in other
1
steps AND is placed between the indications; and in other steps
'
individual letters are used.
Examples;
E-0 step 3
i
Verify Turbine Trip
a. Throttle and governor valves - CLOSED
'
b. Reheat steps and intercepters - CLOSED
'
E-0 step 22
<
Check If SGs Are Not Faulted
4
NO SG PRESSURE DECREASING IN AN UNCONTROLLED
MANNER
N0 SG COMPLETELY DEPRESSURIZED
'
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w
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Attachment B
7
E-0 step 36
Veri fy CNMT Instrument Air - AVAILABLE . . .
b.
CNMT instrument air receiver pressure -
GREATER THAN 95 PSIG
- AND -
Annunciator A6-110, "CNMT
Instrument Air System - Pressure
Low" - NOT LIT
Other examples of these types of inconsistencies found in
the E0F; sampled include:
E_0P
STEP
METHOD
1
Letters
2
Bullets
7
- AND -
13.d.1
Single bullet
14
Letters
24
Single bullet
E-3
17.g
AND
2.a
Bullets
9.a
Numbers
10.a
Bullets separated by - or -
5.
A number of statements in the E0Ps are vague and do not describe specific
operator behaviors.
For example, the operators are instructed to perform
an action "maintain" with no criteria provided as to what the requirements
are.
In order to ensure that procedures are understood, directions should
be defined quantitatively. The following are examples of the use of vague
terms noted in the E0Ps:
TERM
E0P
STEP
Stable (without desired range)
E-0
25.c
21
Maintain (without requirements)
11
31.b
E-3
5.a
As necess&ry
14.a
l
31.a
E-3
25.b
I
i
J
7
_ _ - _ _ _ - _
_
0-
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o'
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Attachment B
8
,
6.
Other weaknesses identified during the review are noted below:
a.
The Writer's Guide includes Table 2, "Abbreviations used in Proce-
dures," yet the E0Ps include a number of abbreviations and acronyms
which are not included in Table 2 or are included in Table 2 in
another form.
In addition, the E0Ps include multiple forms of a
number of abbreviations.
In order to minimize confusion and ensure
consistently prepared procedures, all acronyms and abbreviations to
be used in the E0Ps should be listed in the PGP.
NOT INCLUDED IN TABLE 2
NCO
R
Rad Con
R/hr
V
INCONSISTENT WITH TABLE 2
AMPS vice Amp
amps vice Amp
Ft
vice FT
D/P vice dP
S/G vice SG
gpm vice GPM
b.
The Writer's Guide paragraph V.E.2 states, "the use of AND and OR
within the same action should be avoided." ECA-0.0 steps 32.a aWd b
both contain an AND/0R logic term.
c.
The Writer's Guide paragraph V.F.2 states, "the contingency actions
will be specified for each circumstance in which the expected results
or actions might be achieved." ECA-0.0 step 22.a contains tiie
response not obtained action in the left hand column.
Other
verification or monitoring steps which do not include response not
obtained actions include:
E0P
STEP
ECA-0.0
1.c
ECA-0.0
8
ECA-0.1
15.c
ECA-2.1
31.c
_ _ _ _ _ _ _ -
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_
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. _ _ _ _ _ _ _ _
_
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,
.
Attachment 8
9
.
'd.
The Writer's Guide paragraph V.C.1.a states that expected indications
should be presented in the left hand column.
ECA-0.0 step 22.b
which checks for DC Bus Loads does not specify the expected
indications,
e.
The use of the words OR and AND.in the example in section V.A.3 and 6
of the Writer's Guide is inconsistent with the section VI.C.1 of .the .
1
Writer's Guide which allows underlining of OR and AND only if they'
are used as logic terms.
The use of lower case letters for the
expected response in section V.A.7 of the Writer's Guide is
inconsistant with the section VI.B.1.f.3 statement that "any
condition following a hyphen in the left-hand column should be
capitalized."
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