ML20211N515
ML20211N515 | |
Person / Time | |
---|---|
Site: | Byron ![]() |
Issue date: | 09/03/1999 |
From: | Dyer J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
To: | Lochbaum D UNION OF CONCERNED SCIENTISTS |
References | |
NUDOCS 9909130010 | |
Download: ML20211N515 (6) | |
Text
,
=
~l 4..
a Mr. David A. Lochbaum September 3,1999
~ Nuclear Safety Engineer . l Union of Concerned Scientists m .-1616 P Street NW, Suite 310 Washington, DC 20036-1495
SUBJECT:
' SAFETY CULTURE AND' OVERTIME PRACTICES AT BYRON STATIO'N ' :
i
Dear Mr. Lochbaum:
.We received your letter dated May 28,1999, concoming the safety culture and overtime i n '
' practices at the Byron Nuclear Power Station. We appreciate your willingness to bring these
, .concems to our attention. The specific issues you have raised are summarized and individually. ;
addressed in Enclosure 1.. We are providing for your information a copy of a recent letter from -
the NRC to Commonwealth Edison regarding overtime practices and safety culture
' Enclosure 2. We also appreciate your observation that the May 27,1999 public meeting was
- effective in probing Commonwealth Edison's overtime policy and the safety culture at the Byron ;
Station.
l l lf you have any additional questions regarding these issues, please feel free to contact l Mr. John Grobe, Director, Division of Reactor Safety,' at (630) 829-9700.
Sincerely, '
Original /s/ J. E. Dyer i
J. E. Dyer Regional Administrator
Enclosures:
- 1. Summary of Specific issues
- 2. Letter to Commonwealth Edison j
. 1 cc w/encis: C. Crane, Senior Vice President, Nuclear Operations !
H. Stanley, Vice President, Nuclear Operations . l R. Krich, Vice President, Regulatory Services DCD - Licensing W. Levis, Site Vice President R. Lopriore, Station Manager B. Adams, Regulatory Assurance Manager i M. Aguilar, Assistant Attorney General State Liaison Officer -
State Liaison Officer, State of Wisconsin Chairman, Illinois Commerce Commission DOCUMENT NAME:
., -- we G:DRS\BYRO
.Pg9.WPD See Previous Concurrence
- 1. . co,- - v.c,,. - v.%
OFFICE Rill l Rlli Rill l Rlli l Rlli l NAME- DMcNeil/ W GGrant JGrobe WKane J er DHills:tb DATE- 08/ /99 08/ /99 08/ /99 08/ /99 Of/3/99 4 OFFICIAL RECORD COPY 9909130010 990903 PDR ADOCK 05000454 H PDR
ro ' ' 7
.> 'j i.
.' p l '
I D. Lochbaum ' l
.a 1
Distribution: i
. COT (E-Mail) :.
RPC (E-Mail)
GFD (Project Mgr.)(E-Mail) -
J. Caldwell, Rlli w/enci , ,
B. Clayton, Rill w/enci '
SRI Byron w/enci i
- DRP w/ encl . , ,
DRS w/ encl- l
- Rill PRR w/ encl . l
' PUBLIC IE-42 w/encI .
I Docket File w/enci
- GREENS' LEO (E-Mail) .
. DOCDESK (E Mail)
\.
l l
l 1
l
'I i
J f
I s
i r
e l
$ , .",. >I > L
+
' t'.
t;
. I' '
h' l
c i
Mr. David A. Lochbaum Nuclear Safety Engineer 4 Union of Concerned Scientists '
1616 P Street NW, Suite 310
' Washington, DC 20036-1495 i
SUBJECT:
SAFETY CULTURE AND OVERTIME PRACTICES AT BYRON STATION
Dear Mr. Lochbaum:
We received your letter dated May 28,1999, concerning the safety. culture and overtime j practices at the Byron Nuclear Power Station. We appreciate your willingness to bring these concerns to our attention. The specific issues you have raised are summarized and individually addressed in Enclosure 1. We are providing for your information a copy of a recent letter from the NRC to Commonwealth Edison regarding overtime practices and safety culture (Enclosure 2). We also appreciate your observation that the May 27,1999, public meeting was i effective in probing Commonwealth Edison's overtime policy and the safety culture at the Byron Station, if you have any additional questions regarding these issues, please feel free to contact i Mr. John Grobe, Director, Division of Reactor Safety, at (630) 829-9700. l Sincerely, J. E. Dyer Regional Administrator
Enclosures:
- 1. Summary of Specific issues j
- 2. Letter to Commonwealth Edison cc w/ encl: C. Crane, Senior Vice President, Nuclear Operations H. Stanley, Vice President, Nuclear Operations R. Krich, Vice President, Regulatory Services DCD - Licensing W. Levis, Site Vice President R. Lopriore, Station Manager B. Adams, Regulatory Assurance Manager M. Aguilar, Assistant Attorney General State Liaison Officer State Liaison Officer, State of Wisconsin Chairman, Illinois Commerce Commission '
See Attached Distribution DOCUMENT NAME: G:DRS\BYR0pg_9.WPD vo r.e.w . . , one. noe < inow. i. nom c. . c -a .=en nu.neio. . e . cn e .uchme,w.ncio. r . w em OFFICE Rill E Rlli 15 Rlli j ,l Rill lE Rll!
DATE
$i$:IM 08/ 6/99 MM T.b $dd$I 08d*J99 08/d99 08/14/99 08/ /99 OFFICIAL RECORD COPY
'4 Enclosure 1 Summary of Specific issues 1.- ' The Union of Concemed Scientists questioned the possible use of enforcement discretion regarding violations of. overtime requirements at the Byron Station.
- Byron Station's Technical Specification 6.2.2.e required the implementation of Generic Letter (GL) 82-12, " Nuclear Power Plant Staff Working Hours," to control the amount of I overtime worked by facility staff performing safety related functions. This generic letter contained the Commission's " Policy on Factors Causing Fatigue of Operating Personnel at Nuclear Reactors." Byron Administrative Procedure 100-7," Overtime Guidelines for !
Personnel," further clarified Byron Station's policy on implementing the overtime I technical specification requirements. The Regional Administrator for NRC Region lli made it clear during the public meeting conducted on May 27,1999, that any violation of Commonwealth Edison's (Comed) procedure requirement for prior approval of overtime guideline deviations was unacceptable. The technical specifications for controlling overtime utilization have been the subject of a Notice of Violation at the Byron Station in the past. Specifically, in January 1995, the NRC issued a violation to the Byron Station for the failure to have overtime deviations reviewed and pre-approved by the Station Manager or designee. In addition, based upon the information provided more recently by Comed, we determined that, although improved, problems persisted at the Byron Station with regard to prior approval of overtime deviations, and that a Non-Cited Violation was appropriate (Enclosure 2) in accordance with the current NRC Enforcement Policy (NUREG-1600, " General Statement of Policy and Procedure for NRC Enforcement Actions").
The NRC is reassessing the Commission's " Policy on Factors Causing Fatigue of Operating Personnel at Nuclear Reactors" and will be considering altemative regulatory 3 approaches as part of this process. In addition, Comed committed during a July 13,1999 public meeting with tha MRC'e Comed Performance Oversight Panel (CPOP) to take action to ensure the GL 82-12 work hour guidelines are met at all Comed nuclear power plants and corporate facilitbs. Based upon Comed's commitment, we will not attempt to further evaluate the work hour statistics Comed presented or determine whether other violations occurred regarding the quantity of
- overtime worked at the Byron Station.
- 2. The Union of Concemed Scientists questioned the basis for reliance on the relationship between overtime utilization and the occurrence of human performance events as an indicator of whether operator overtime utilization affected plant safety.
Byron Station's operational safety performance has been good and the data supplied by )
Comed showed no correlatico between overtime and human performance events.
However, the NRC acknowledges that fatigue can play a role in causing a variety of human performance errors at an operating station and understands that the operational ,
event data presented by Comed would not be indicative of all manifestations of fatigued !
Workers. ;
n
- 3. The Union of Concemed Scientists questioned the candor and willingness of Comed management to speak freely in the presence of NRC management.
The NRC believes that, while we do not agree with all Comed's conclusions, investigative techniques, or characterization of overtime statistics provided during the May 27,' 1999 public meeting, the Comed managers presented their response to our concems in a candid and professional manner. The candor exhibited by Comed's management during the meeting is consistent with their approach during other meetings
' with the NRC. In particular, the NRC's CPOP has conducted public meetings with Comed management approximately every two months for the past two years to assess performance improvement efforts at the Comed nuclear stations. During those meetings,' Comed management has been very willing to share their thoughts, both positive and negative, with respect to plant performance. There is no evidence to suggest that Comed management was any less willing to express their viewpoints during the May 27,1999 meeting.
- 4. The Union of Concemed Scientists questioned the basis for the Comed analysis of overtime impact utilizing average overtime data for Byron Station staff when fatigue induced human error is an individual issue similar to other Fitness-For-Duty concems.
We agree with the Union of Concemed Scientists that fatigue could result in a Fitness-For-Duty issue affecting individual performance. Even though Comed used average numbers in their presentation during the May 27,1999 pubhc meeting, they also presented specific data on individual operators to clarify the statistics. We evaluated the information Comed presented and concluded that a violation occurred for Comed's failure to adequately control the use of overtime. Specifically, overtime deviations had not been approved prior to the overtime being worked, and therefore, was a violation of station procedures.
. 5. The Union of Concemed Scientists questioned the basis for the NRC's guidelines that allow a greater dependence on overtime use during outage periods and contrasted the GL 82-12 guidelines with other Fitness-For-Duty restrictions in 10 CFR 26.
Since 1982, the NRC has assessed licensee control of overtime for plant personnel who perform safety-related functions by ensuring that licensees comply with plant technical specifications and administrative procedures that are consistent with the Commission's policy statement. The policy (contained in GL 82-12) sets guidelines for the control of overtime and allows the flexibility for licensees to deviate from the guidelines when they can justify that such deviations would not result in significant reduction in personnel effectiveness. Currently, the NRC is revising its overall reactor oversight process to ensure that the process is more objective and clearly focused on the issues most important to safety. At present, the NRC does not anticipate that the new oversight process will include routine review of licensee use of overtime. In light of the NRC's preliminary review of this issue and the anticipated changes in the reactor oversight process, the NRC is reassessing the Commission's " Policy on Factors Causing Fatigue of Operating Personnel at Nuclear Reactors" and will be considering attemative regulatory approaches as part of this process. The NRC will continue to follow up on 2
't 4
' safety significant occurrences to determine the root cause, including the potential contribution of personnel fatigue, and make adjustments to our regulatory program where appropriate.
6.~ The Union of Concemed Scientists questioned the adequacy of the assessment Comed completed and challenged the Comed conclusion regarding the safety conscious work environment at Byron.
We concluded that the self-assessment of the Byron Station work environment could have been more effective by using different methods of gathering data. However, we generally agreed with the results of the investigation and concluded that a substantial majority of the Byron Station work force is willing to raise concems.- A chilling effect by its nature can exist because of personal perceptions of retribution for raising safety concerns, and management action, intentional or not, can influence an individual's perception. We determined that there was a chilled environment within the operations department. Comed has taken actions to improve the work environment in the -
operations department at Byron Station. Comed has also taken actions to correct misconceptions conceming problem identification forms and NRC/ Illinois Department of Nuclear Safety contact forms. These actions should contribute to an improved work environment at the station. Comed will also conduct a cultural assessment, and we have requested that Comed submit the results of the assessment to the NRC. We expect that there will be improved techniques employed in the next survey. We will carefully review the survey methodology and results when they are made available to us.
I
- 7. The Union ofConcemed Scientists emphasized the importance of providing feedback to concemed individuals and questioned whether the NRC was reluctant to cite violations identified through the allegation process, j The NRC values information regarding safety concems at NRC regulated facilities that is brought to its attention by concemed individuals and is strongly committed to responding to these individuals to ensure that their issues are properly evaluated. In accordance j with the NRC allegation process, the NRC intends to respond by separate correspondence to the concemed individuals regarding the resolution of the Byron Station safety culture and overtime practice issues. The NRC followed the provisions in NUREG-1600, " General Statement of Policy and Procedure for NRC Enforcement Actions," for enforcement decisions regarding Byron Station overtime practices. The NRC treats all violations in accordance with the Enforcement Policy regardless of the source of the underlying concems. The NRC will consider stakeholder input when changes to the NRC allegation or enforcement policies are made.
3 l
n '
l g Enclosure 2
- qa na4 UNITED STATES 9
- /
[
g n NUCLEAR REGULATORY COMMISSION REGION lli
!! y 801 WARRENVILLE ROAD
- LISLE. ILLINOIS 60532-4351 S ,g # September 2, 1999 i
l EA 99-179 Mr. Oliver D. Kingsley President, Nuclear Generation Group Commonwealth Edison Company ATTN: Regulatory Services Executive Towers West lli 1400 Opus Place, Suite 500 Downers Grove,IL 60515
SUBJECT:
BYRON OVERTIME AND WORK ENVIRONMENT CONCERNS; INSPECTION REPORT 50-454/99011(DRS); 50-455/99011(DRS) ]
1
Dear Mr. Kingsley:
On May 27,1999, the NRC met with Commonwealth Edison Company (Comed) and Byron Station management to discuss concems regarding overtime practices and the conduciveness of the work environment to raising safety concems at the Byron Station. The NRC acknowledged that the Byron Station safety performance has been good as documented in our I recent Plant Performance Review (PPR) Report issued on March 26,1999. However, the impact of fatigue on human performance and a work environment that facilitates individuals raising safety concerns are critical cross-cutting issues that could affect performance in all safety areas.
The results of your evaluations and responses pertaining to our requests for additional information regarding Byron Station overtime practices and the Byron Station chilled work environment concem were provided in letters from your staff dated April 30 and May 26,1999, respectively. In addition to the receipt of the letters, we appreciated the efforts of your staff in presenting Comed's viewpoints regarding these issues during the May 27,1999, public meeting held at the NRC Region ill office.
Based on a review of the Comed letters and the public meeting presentation, we understand that Comed has concluded that the use of overtime at Byron Station: (1) was controlled in accordance with the administrative requirements and management expectations established to meet the overtime requirements of the Technical Specifications; (2) did not cross into the realm of routine; (3) was not the result of inadequate staffing to support the operational requirements of the station; and (4) has been controlled in a manner consistent with safe plant operations.
After reviewing the correspondence and public meeting presentation, we are unable to support all of your staff's conclusions conceming the appropriate use of overtime at the Byron Station.
l SC90960*19
t 4
O. Kingsley - - In particular, your staff concluded that overtime was being controlled in accordance with 3 established management expectations, yet 2.2% of the overtime deviations had been approved after the overtime was worked in violation of station procedures. Specifically, Byron Technical
- Specification 6.2.2.e required that administrative procedures be developed and implemented to limit the working hours of facility staff performing safety-related functions. Byron Administrative Procedure (BAP) 100-7, " Overtime Guidelines for Personnel," Revision 11, required prior ,
approval of guideline deviations. The corrective action taken to address a previous, similar violation issued in 1995 reduced the rate of occurrence of these violations but was not fully effective to prevent recurrence of "after the fact" overtime approval. Your staff failed to identify the problem through your self-assessment program until prompted by the NRC. This violation has been entered into your corrective action program through Self-Assessment SF-SS-103, Revision 1, dated May 14,1999.
This Severity Level IV violation is being treated as a Non-Cited Violation (NCV), consistent with Appendix C of the NRC Enforcement Policy (50-454/99011-01; 50 455/99011-01). This violation was discussed between Mr. J. Grobe of my staff and Mr. W. Levis of your staff during a telephone conference call on August 25,1999. If you contest the violation or severity level of -
the NCV, you should provide a response within 30 days of the date of this letter, with the basis for your denial, to the Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington DC 20555-0001, with copies to the Regional Administrator, Region 111, and the -
Director, Office of Enforcement, United States Nuclear Regulatory Commission, Washington DC 20555-0001.
In addition, your staff concluded that overtime usage did not cross into the realm of routine and that staffing has been maintained to support the operational requirements of the station. On i average, the Byron Station management approved more than one overtime deviation each day l the plant was operating. The deviation approval rate for outage periods approached ;
. nine deviations per day. Your staff indicated that the majority of those deviations represented ,
employees' working in excess of 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> in one week. The data supplied by your staff l indicated that control room operators worked an average of 7.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> of overtime per week during non-outage times. We believe that the station's overtime practices may not have met the guidelines of Generic Letter (GL) 82-12 as required by Byron Station Technical !
Specifications with regard to work hours during a normal work week and the frequency of overtime deviations during outages.
The NRC is reassessing'the Commission's " Policy on Factors Causing Fatigue of Operating !
Personnel at Nuclear Reactors" and will be considering attemative regulatory approaches as part of this process. In addition, we acknowledge your staff's presentation during the July 13,1999, Comed Performance Oversight Panel (CPOP) public meeting in which you committed to take actions to ensure the GL 82-12 work hour guidelines are met at all Comed nuclear power plants and corporate facilities. ' Based on Comed's commitment, we will not attempt to further evaluate the work hour statistics your staff presented or determine whether other violations occurred regarding the quantity of overtime worked at the Byron Station. We will continue to follow up on safety significant events to determine the root cause, including the potential contribution of personnel fatigue.
s
-t.
O. Kingsley Regarding the chilled work erwironment concem at the Byron Station, your staff conduded that overall a safety conscious work environment exists and that employees are willing to raise safety concems._ However, your staff also conduded that there was a chilled work environment and a need for improvement in the operations department. During the May 27,1999, public meeting, your staff stated that there had been significant management personnel changes at the Byron Station and the new management team was committed to maintaining a work environment conducive to the raising of nuclear safety issues. Finally, your staff stated that Comed planned to perform an additional assessment of the safety conscious work environment in the near future.
We reviewed the information presented during the public meeting and your letter dated May 26,1999, responding to specific questions the NRC posed about the chilled environment concem. The NRC concluded that your self assessment of the Byron Station work environment could have been more effective by using different methods of gathering data. Notwithstanding, the NRC agrees with the results of your investigation that a substantial majority of the Byron
. Station work force was willing to raise concems. However, a chilling effect by its nature can
- exist and detract from a safety conscious work environment.because of personal perceptions of retribution for raising safety concems. Management actions, intentional or not, can influence an individual's perception. We agree that there was a chilled environment within the operations department that was not conducive to a safety consdous work environment. Your staff has taken actions to improve the work environment in the operations department. In addition, your staff has also taken actions to correct misconceptions conceming problem identification forms and NRC/ Illinois Department of Nuclear Safety contact forms. These activities should contribute to an improved work environment at the station.
In summary, we conclude that your staff violated NRC requirements concoming overtime deviation approval. We encourage your continued efforts and commitment to control the use of overtime. We believe that a chilled environment existed in the operations department and acknowledge your actions to enhance that work environment. We appreciate your commitment to perform a follow-up self-assessment of the safety conscious work environment and request that you submit to NRC Region lli the results of that assessment and any further actions. We recognize that your actions to address problems with overtime control and to ensure a safety conscious work environment are in process and we will continue to evaluate your progress in these areas.
Enclosed with this letter is a letter from the Union of Concemed Scientists (Enclosure 1) that provided comments on the May 27,1999, public meeting, and a letter from a concemed individual (Enclosure 2) concoming the validity of the investigation conducted by the Comed Nuclear Oversight Organization. These letters are enclosed as they address similar concerns the NRC has addressed in this letter. They are provided for information only. Also enclosed with this letter is 6 copy of your staff's slides that were presented during the public meeting (Enclosure 3). An inspection report number has been assigned to this letter only for NRC tracking purposes; an inspection report is not enclosed. We appreciate your cooperation and will gladly discuss any questions you may have conceming this information.
l
F.
\
O. Kingsley i If you have any questions regarding these issues, please feel free to contact Mr. John Grobe, Director, Division of Reactor Safety, at (630) 829-9700. In accordance with
- 10 CFR 2.790 of the NRC's " Rules of Practice," a copy of this letter and your response will be placed in the NRC Public Document Room.
Sincerely, M
J. E. yer Regional Administrator Docket Nos. 50-454; 50-455 License Nos. NPF-37; NPF-66
Enclosures:
As stated -
cc w/encis: D. Helwig, Senior Vice President, Nuclear Services C. Crane, Senior Vice President, Nuclear Operations H. Stanley, Vice President, Nuclear Operations R. Krich, Vice President, Regulatory Services DCD - Licensing W. Levis, Site Vice President R. Lopriore, Station Manager B. Adams, Regulatory Assurance Manager M. Aguilar, Assistant Attomey General State Liaison Officer State Liaison Officer, State of Wisconsin Chairman, Illinois Commerce Commission )
l 1
j
g Enclosure 1 UNION OF CONCERNED SCIENTISTS May 28,1999 Mr. James Dyer, Regional Administrator United States Nuclear Regulatory Commission 801 Warrenville Road Lisle, IL 60532-4351 SUBIECT:
SAFETY CULTURE AND OVERTIME CONTROL AT BYRON
Dear Mr. Dyer:
1 observed the May 27,1999. NRC public meeting with Commonwealth Bdison (Comed) regarding safety culture and ovettime control at the Byron nuolcar plant from the videoconference location at NRC headquarters. The meeting did little to allay my conoems about these important safety issues.
In your opening remarks, you stated that while the NRC was concemed about the safety culture and evertime control at Bryon, these matters were not in enforcement space. ~the subsequent discussions made it abundantly clear that the NRC is not in enforcement space because the agency has essentially exercised enforcement discretion regarding violations at the plant. For example, you stated that an audit in or around 1996 revealed that approximately 10 percent of.the authorizations to exceed the ove: time guidance in Byron's technical specifications were made afterwards instead of prior to the work as required by Comed's procedures. You further stated that a more recent audit revealed that these overtime authorization procedure violations have been reduoed to about 2.5 percent. The NRC could, in fact, cite Comed for these repetitive pmcedure violations since Bryon's operating license and federal regulations
' . require procedures to be followed. Thus, the NRC is not in enforcement space because you have exercised enforcement discretion for these and other violations.
In your concluding remarks and in your statements to the press, you placed considerable weight on Comed's alleged demonstration that worker fatigue has not played a role in event ooounence at Byron. I examined the company's submittals and listened to their presentation, but failed to see how you arrived
. at that position. It may very well be true tlist the events did not occur during a period of heavy overtime.
Yet Comed went to great length to explain that much of the overtime worked by licensed operators was not on the boards in the control room but perfonning tasks like training and surveillance test reviews t f;tigued worker can fail to absorb key safety information during training or fall to adequately revieu est results. The consequences from these performance impairments can contribute to events weeks or months later. In addition, Mr. Peny of Comed stated that Nuclear Oversight found overtime levels by other departments at Byron to be comparable to that from the Operations department. In purportedly showing no link between overtime and events at Byron, Comed only presented data on operator evertime. I know from personal experience as a reactor engineer at operating nuclear plants that the Washington omce: 1616 P Strwet NW Suite 310 . Washington DC 20036 1495 202 3324900 . FAX: 202 332 0905 Carnbndge Headquarters: Two Bratte Square . Cambridge MA 02238-9105 617 647 5552 . FAX; 617-864 9405 Cantornia Omca: 2397 Shanud Avenue Suite 203 . Berkeley CA 947041567 51o4431872 . FAX: 510-643 3785
i May 28,1999 Page 2 of 4 heavy overtime periods for many plant departments is not necessarily concurrent with outage times.
Resotor engineers and others work long hours supporting the restatt of a plant from an outage. Other workers put in long hours preparing for an upcoming outage. It is conceivable that fatigue on t a worker other than a licensed operator could have contributed to a Byron event. Thus, Comed's superficial presentation on this subject was by no means conclusive and o should n_ot be used to excuse their overtime control practices.
Furthermore, your acceptance ofComEd's position on the link between overtime and safety contradicts the sound argument raised by Mr. Orobe ofyour staff regarding the " chilling effect" of Comed's sa 4 culture investigation technique. Mr. Orobe maintained that having Comed's lawyers interview Bymn j workers under oath and with transcribed testimony may have prevented these workers from open and
- free responses to questions. Mr. Orobe pointed out that licensed operators are required by the terms of their licenses to raise safety concerns and their careers might be compmmised by stating, under oath before the company's lawyers, a teluctance to do so. By the very same token, Comed's license to o Byron contains terms which require them to use workers who are Ace from impairment by drugs, alcohol, fatigue, and other causes. %us Comed could not find a link between overtime and potential unsafb operation of the fbottity without providingprimafsets evidence that it had violated the terms of Byron's operating license. It's not clear why the NRC is worried about workers being hesitant to spea 6 eely but is not worried about Comed being hesitant when both are ikcod with the same intimidating pressure.
It is also unclear why Comed and the NRC placed such hnpuimoe on the link between overtime and safety. %e NRC's fitness-for duty requirements contained in 10 CPR Part 26 must be followed by all workers and plant owners at all times - notjust when workers are performing safety-related duties. To my knowledge, there has never been an attempt by any plant owner or the NRC to dismiss / downplay drug or alcohol abuse on the basis that it did not conelate to events at a plant. Yet, that approach was taken by ComBd agarding fatigue at Byron and is being entertained by NRC.
De approach taken by ComBd to address overtime at Byron was disappointing. De guidance on overtime pmvided in NRC Generic Ietter 82-12 and essentially duplicated in Bryon's technical specifications apply to individual workers, yet comed nlied almost exclusively on average overtime
' worked. ne strength of a chain is dictated by its average link but by its weakest link. It matters little if {
99 out of 100 links are inciedibly strong and durable if the remaining link is terribly weak. Likewise, the Itness-for duty requirements would be worthless if applied on an average basis - the 0.04 blood-alcohol i content limit would be turned into ajoke if a company applied it on an average worker basis. %st would permit four totally drunken workers to be balanced by ninety-six teetotalers. Ofcourse, the NRC does not tolerate such shenanigans. But, the agency appears poised to allow ComBd to get away with mathematical magic when it comes to overtime at Bymn.
It is equally baffling why Comed places so much emphasis on the amount of overtime worked during outages compared to that worked when the plant is operating. De safety concem associated with evertime is worker fatigue. The need for overtime increases when a nuolear plant shuts down because there so much maintenanoe, tests, and inspections is performed on safety equipment then because it cannot be conducted when the plant is running. It is just as important that safety-related work be
. performed by workers free from fatigue-impairment during outages as during operation. Yhtually all
. :ireraft maintenance is perfonned when the plane is on the ground. De fact tivat the plane is not in the ;
air at the time does not allow the FAA or airline companies to condone dnmken or fatigued maintenance '
- osews. Nor does the fact that a nuclear plant is shut down obviate the need for maintenance, tests, and l
s . n,.. . , . s . .o ... - -
g-a ,
May 28.1999 Page 3 of 4 inspections of safety equipment to be performed by capable workers free from the effects of fatigu
%c lessening of overtime controls during nuclear plant outages also contradicts other established
. requirements. For exarnple, the fitness-for-duty requirements contained in 10 CFR Pan 26 apply unifonnly at all times not more so when the plant is mnning. De NRC would not tolerate any licens bringing a boer tmck up to the front gate and passing six-packs out to workers entering the an outage. Yet, the agency appears ready to allow Comed to set aside overtime controls during ou 4
I hese actions have virtually the same effect. Numemus safety studies have consistemly demonstrated
, that fatigue impairs human performance very much like alcohol.
Comed's presentation on the safety culture wu equally disturbing. I wholeheartedly agree with ma the concerns expressed by numerous NRC staffers during the meeting about the survey conduct i ComBd's "indarad~it" team. Hat safety culture survey was a travesty, ne team's conduct reflected a '
very clear bias against finding a safety culture pmbicm at the plant. For example, the team leader sta that appmximately 20 percent of the persons interviewed volood some level of reluctance to write a Problem Identification Fonn (PIF). fic stated further that the team followed up on this observation by i reviewing the PIF database and detennining that these ' reluctant' workers were indeed writing P!Fs. He summarily discounted the impsi .c. of this su:vey tesult based on the team's followup work. Yet, it is i not apparent that the tearn performed comparable followup work relative to the 80 percent of the people who expressed no reluctance to write PIPS. Does the PIP d*he confiron that those people are in fact writing PIPS? Mr. Stanley semi-addressed this question when he stated that some workers never write PIFs because their supervisors write them instead. nat statement appears unsupported by the data gathered by the survey, although it may very well be true. In any case, it is apparent that the i
" independent" team started with the promise that a good safety culture existed at Byron. De team apparently accepted data which supported this position on faith and selectively chose to refute only that data which challenged this position.
Finally, in your closing remarks you gave ComBd credit for corrective actions taken or planned to 1
'enhanoc' the safety culture at Bymn. You specifically cited Comed's changes to the PIF procedure which pmvides better fdhm+ to the FIF initiators. I respectfully request that you conalder comparsble changes to your own policies and procedures for treating nuclear werkers who bring sinocte safety concems to the NRC. By overlooking Comed's violations and allowing the company to 'enhanoc' its safety culture and overtime contmis at Bymn, you may be improving safety levels at the facility but it comes at a very high prioc. By emphasizing future compliance rather than past non-compliance, you are de-valuing the role of dediosted nuclear profesalonals who bring issues like these to your agency. But for the actions of these nuclear workers - who have risked their careers -it is highly unlikely that ComBd would be now taking these conective measures. Dese issues were first raised to ComBd long ago, but the company handled them improperly. Dese issues were then raised to NRC. De NRC's interest is only now inducing the company to fix the problems. It is just as important for the NRC to provide complete and accurate feedback to people making allegations as it is for ComBd to provide that feedback to workers initiating P1Fs. He consequence of failing to do so is identical- workers stop writing PLFs and people stop submitting allegations to.the NRC. De NRC's extreme reluctance to cite nuclear plam cwners for' violations identified via the allegation process is a " chilling effect" that dissuades future i allegations.1 can attest to this from my own personal experience before and since joining UCS. i 6
~
m ......i c , o . # m . ..,
a.,4 t.,*, ,s. . . . . .
t May 28,1999 Page 4 of 4 To be fair, the encouraging aspect of the meeting was the many probing questions asked of Comed's represcatatives by you, members of your staff, and members of the NRC headquarters staffin Rockvill It appeared that the NRC did not simply rely on Comed's assurances of better future performance, b expects to see tangible evidence ofimprovement. I hope that you will ensure the NRC takes aggressive actions to ensum that Comed meets those expectations.
Sincerely, David A. Loch aum Nuclear Safety Engineer 1
l 1
1 e
i
r 3
y 4: a-Enclosure 2
...' I i
. May 25,1999 - !
I i
Jack Grobe
, Director, Division of Reactor Safety -
U.S. Nuclear Regulatory Commission Region III - ;
801 Warrenville Rd. i J
Lisle, IL 60532-4251 l
Subject:
Comed's Responses to Chilling Effect and Overtime Concerns )
1 i
Dear Mr. Grobe,
- This letter summarizes concerns ~with a chilling effect and overtime abuses at Comed's d Byron Station. As a member of the public, I request that this letter be made part of the permanent record of the meeting on 5/27/99.
J Chilling Effect Comments . .
The corrective actions from Comed's chilling effect investigation have not been fully l effective - this should be no surprise since the corrective actions were without substance. !
The corrective actions only dealt with symptomatic fixes since Comed said that there was
. no need to determine the true root cause of the problem with the work environment. )
Evidence of the failure of the corrective actions is found in the following two examples, j The handling of multiple concerns since the beginning of 1999 on the quality of operator j training shows that Comed either does not understand or does not care about the cause !
and effect relationship between ignoring concerns and employees going to the NRC. !
Concerns raised by some licensed operators regarding the startup of Byron Unit I with loose parts in the Reactor Coolant System were met with written and verbal comments j that made it clear that tome management wished they would just shut up. The operator -
l comments were dismissed as ' editorial'. Based on my experience, Comed's working l
definition of an editorial comment is a comment that is both true and troublesome.
! Why did Comed's Nuclear Oversight Organization (which fulfills the 10 CFR 50 Quality Assurance role and is required by regulations to be independent from line management) l fail to correct the long-standing problems with the work environment despite multiple l
chances to do so? I have seen no evidence that Comed even attempted to find out why.
L Comed's only action acknowledging Nuclear Oversight's role was a feeble letter to the
- Nuclear Oversight auditors which basically said 'do better next time'. NRC Inspection l Procedure 40500 on Corrective Actions has criteria for evaluating the effectiveness of l
Nuclear Oversight - what role will the current problems play in the next inspection in this area? ;
MAY 25 1999 l
( 476769h !
c k
J A February 1999 Byron issues report prepared at the request of Oliver Kingsley stated L that 3 people had made 10 allegations to the NRC in 908 What is the purpose of l p presenting this information to the president of the Nuch- i%eration Group? A noble j l . purpose would be to ask the allegers what was wrong wi n ie Comed internal processes
. that caused them te go to the NRC. This has not occurred in the 3 months since the
~
report was published. What other purposes exist? Since you can't fire a whistleblower until you know who he is, identification would be a logical first step.
t Between May~ 18 and May 20,1999 Comed conducted another investigation into why- }
people were going to outside agencies. The interview list for this investigation looked odd 1 to say the least.' Given that the company made the effort to find out who has been go'mg to the NRC why didn't the 3 people whose identities were known in the February 1999 Byron Issues report get' interviewed? Is it so Comed can come to this meeting today and -
say 'We looked and didn't find anything'?
l Senior Reactor Operators have been among the more vocal and critical ofissues at Byron.
A potential employer recently notified 3 SRO's that their job interviews were' cancelled.
Some believe that Comed contacted the prospective employer and requested that they not hire any more Comed employees, especially those from Byron. Aside from the poor management practice of failing to recognize that competition applies to employees as well as custorners, does this constitute illegal blacklisting since it punishes the vocal and critical !
SRO group?.-
The rise in the number of allegations at Byron is significant:
1996 5 1 1997 11 1998 18 (3 still open) 1999 8 (through 4/30/99)- l Also noteworthy is the ' quality' of Byron's allegations - For the 4-year period of 1995- {'
1998, 42.9% of Byron's allegations were substantiated by the NRC while the national '
average for the same period was 37.2%. Not only is the number increasing, real problems are being identified that Comed failed to deal with. Eight allegations so far in 1999 puts i Byron in 4th place behind St. Lucie (16), Millstone (13) and San Onofre (10). Comed has finally achieved top quartile performance, but in the wrong quartile.
Allegations to OSHA have also accelerated at Byron, hard numbers are not available but 1 i would estimate 3 so far this year. Why doesn't the NRC include the number of OSHA allegations when it evaluates the health of a licensee's safety conscious work environment?
~
The NRC r'equested that Comed conduct an independent investigation. Instead, Comed
~
brought in Winston & Strawn, a law firm' that frequently' represents Comed. The company's web page says 'We have defended licensees and contractors against numerous i whistleblower claims'. During a' debrief on 1/15/99, the attorney would not provide some l
2-
1
-4 t.
u>
' information to personnel interviewed for the investigation since it was " attorney-client" material not' subject to third-party disclosure.' The independence of the investigation warrants review.
The investigation resulted in over 2,000 pages of transcribed testimony, a report of about 200 pages but less than a 10-page response to the NRC. Is the NRC basing its decision
- solely on this meeting and previous correspondence? A more infonned decision could be reached by reviewing the source materials.
The NRC has a role in Byron's declining performance. Why did it take over 4 years to even begin to address this issue? Missed opportunities include a chilling effect allegation in 1995 (RIII-95-A-0020) and a harassment complaint filed in 1996 by a Senior Reactor Operator after concerns were raised regarding fire protection issues and the effectiveness of the corrective action program (RIII-96-A-0142). The current case is not particularly timely either - over a year has passed since the concern was first brought to the NRC's attention.
Why didn't the NRC's corrective action inspections under IP 40500 detect that Comed's corrective action program frequently failed to resolve is' sues? A partial answer may be in the NRC allowing inspections to do ' double duty'. The 1996 Corrective Actions
~ inspection took credit for the investigation into the 1995 chilling effect complaint. The 1998 corrective action inspection used the results of a team inspection in the engineering area to meet the requirements ofIP 40500. The problem here was that it solely focused on engineering corrective actions, despite information that showed problems existed in other areas..
A conflict exists between an April 14, 1999 letter regarding Allegation RIII-98-A-0105 and the wording of the subject of this meeting. The letter says the NRC concluded that
' the concem of a chilled environment was substantiated since the environment was not .
always conducive to the open raising ofissues. This conflicts with the wording of the notice for the current meeting which only discusses a ' potential' chilfmg effect; it appears that Region III is straddling the fence.
Implicit in the NRC's new program for monitoring licensee performance is a reliance on a licensee's corrective action program and their quality assurance program Given that these were deficient in the current case and the NRC took 4 years to get around to dealing with it, what reasonable assurrnces does the public have that problems like those at Byron will not occur again at Byron or at other licensees?
Byron Station's environment is not conducive the open raising of issues and Comed's corrective actions are without substance therefore NRC must step in and take action.
Overtime Comments - l Frustration with Comed's refusal to address the overtime issues in the Operating Department at Byron caused the issue to escalate to the national level. My comments l
p 9
! ' here are limited to Byron's responses to the NRC. Generic issues with overtime are being pursued in other venues.
l The metric selected by Comed to respond to initial NRC questions was the average number of paid hours. This misrepresents the hours worked by management, since some l
are forced to work uncompensated hours. The payroll records don't always include the
- forced hours, therefore the hours worked by management are understated. The NRC l l noted this same logical flaw in D.C. Cook's tracking of overtime (See Inspection Report a 50-315/99004). ! Also used was the average number of hours, this is a misuse of statistics l l since it is not the average operator that is going make a mistake but the one working 50% I l over the average. Another odd statement was that the operations department personnel had increased from 152 in 1995 to 172 in 1998, this partially appears to be increases in
, staff members who do not operate the power plant. This statement puzzled many operators since we haven't seen these 20 extra people. Did Comed average in staff l members with low overtime to bring the numbers down?
1 l I have left out some details to protect the privacy of those involved. If further m
" formation i is needed Ican be reached at:
t I
R fully, <
1 Barry ,S or or Operator 4
L
l t
i e
e _
i m -
p t r
u e o
r v _
G O n nd oia on 9 n I
i t 9 t at 9 n at rS n 1 oLI e e i g
nnm 7 e e 2
e on y Rl s i
Gr yr o a CL rBi MR a v N e n l
c K u k N o r
y n
a W C p
m o
m o
i c
n U
A
s i
s .
ve
~ L .
/
W _
y y y _
e e e n
l l l n n y n o t a t a r r t a
i S S e S t P t
a G G
S G
n H H
J. 1 1
e s
e r
P t n
f e o m k s
e n r o a i
n n o i r m l i t v e t c n e R u d u E i m g n
O o r
k r
t r
e i
s t o v o I
n W O l
C y dp an Eom mCocm oin CUA
9 9
t n
e m y n e o l ni s r a v i
v t e n SL C
I G. W.
k I.
r I o
W y
n dp a Eom mCmoc oin CU A
e _
b .
t a s s
s e _
t s r _
n i x d o e d i t t y s a a t n e e o a e f a
r t a
l u m n
s e e n e
a v i o
r i s
a mka o
E v r s t n
e o i n g t
t k g t n n n i _
r n e o e e '
n w i
l l
e mbs m o s i
w v n n i s u e o os o u ono i r r ie p t r a mcassu l
c c i i
v n st na s e i o ot e s r n C cS yn o ei vd e K ynlor f pc e d i
e o l t t i l
k r e cf r
af r a y mn o e ei rt o e SBEc N r n v o e WO -
Cid
- y dp an Eom mCom oinc CUA
g r n
a n
i t e e .
v o a l c i i
t r u t .
a e c _
N p e .
c f _
O y f i
f i f b e _
r o e y -
et c d l n e t l Vennn ymmmt e a k e to a n f
t u
o t
s s r t n
i l s s o s n ae ef s n e n _
r o o us s e a pt i m e i t
QsAd t c
a vo c a
e e n e r t
e e t a v pt v i
S i
t i
nr tmimh t
c ii gt i
c 6 i a er e rs e r
9 9
f-l p
e e o r me o v r
o 1 SDCSOC
- - - - y dp an Eom mCmoc oin
~
CU A
0 5
s _
n o r _
e t _
c s n
d _
8 o n _
9 ct ,
o n8 9 f p _
o e 9 s nm9 1 e
, 1 r 6 i oe g0 2 t 9 9 d a a 2 s 9 n r g9 9 n u a 9 d a l
e in1 1 n
u5 aMb e
v mn d 8 6
o t s n i 1 2 r s u n no vef h s a y g g e r ai t a on o c n r o s k u cn det c Ao Ni S f ta aiMnt s fi o a f c cf t o
B of o duot erl a fo q er e uMe u ot s s s nn t v p t u q
r e oe t e r u t e
t l
p cd l e t e - e p d wl t
e md nd e t e o d u-l a C e C d l l C
I p I l o I w
C Ex me mvC i
R - od n o o F mo r R l
- ol N CiCpN Cfdp o y n
a Emo mCmoc oin CUA
ht i
n n w
o s s t d t i o n n m e
v nt a ua i t
w e o e c a i i
t d
n a
e l
o fi a viv l mrv r e s
e u
T n n o t
e i g e f n q .
p t t i f o ni f n s e n ni y o _
d n e e ht e od n a r t d mipi e _
noi n e wty t a u n s s .
r o i
I t e g s r mla d
r e a p a ri s a u a h u e n eh p gi l d
a bt d k. ed _
t l e c ri n f a n Mmir n a pv a o v i
I e e pb dd t
f n mc n s
K o o n nd e cte id w i e e o e n r ta di r it we u fic s t e r i o e S ts e ai i
di a v
r i
t b o up u ve once p e
c r
..e v
e mNOx e y e
l arcs p P
m-l e c - - -
O S I y
- - n a
p m
o C
m o
i c
n U
A
m -
r -
o s F t n
t n l e
e o n m n i t nt t
r e n a o en a p
d o c s e e trmdr i r n i t
a i
f p a e e u nt n n p h p l i o e o D e t o
e a t a d s s i t
d n v e t I d wtas s
n o
m o
r no ~
s f n mnre e i t
f I i o e e i 0 a l e
t s ml v0 er n e a e c e p u bod t
er1 p n o
u c r n t > On s
h o
o r -
nd e o t l r c o Pa i e
p f a p s d d wde oyC e d d n v e te a tc v cu t
a e e s i
d t
e c
e wI e
i t
oi s wad n ile u) d t F u r o e
l S
e i a te v a F nI n - -
v r l u x e vP I
o - _
e aERE( C _
v v - - - -
K O -
y -
n a
p _
m o
C m _
o i
c n
U A _
E
s t o -
t -
n t d
e e n t d n _
n i c
e g e n m e
i s s n
d e -
i v d o _
n d l o y i
t e e p p y t v l a e a
g n l c
e o s
e o l i t
c r d nl uis n i
f e noi o s f d
s o
e ip c
ed I t I mt n pn e a of o
t c e e s a h
t l uhte s s
a p
gd ai n c e e s
f a me ma n vu o C v ni e mf iis t ai s n v al o v y wI e i t
oi s a
i t
f nl e o e r rf ei i a v e u st nn v
r l u r e
t o
vt e a oe P LNCi d e aP v v - - - - -
O K
- y dp na Eom mCmoc oin CUA
I I { I a
s e e d s h u e g t s s t a s i
n t o
i yt s r e u
t n s d e f e
o s i
n i v a s mes i
F c u s e
e d ia s r n
i d n a ic o o nr r h t i o c e t o te d.
t c e a nt nt e uy s l
u t no a f s a e cits a s n y mty e r a
h e C
I ne t a
e m f of a o lc e r n s s uiv o i vf y r nt a r no e g n e g kr n r a k n o tor te l m riWS oi s A m
u War - - -
S -
y n
dp a Eom mCocm oiUn CA
s g d r e i
n i o i z
d va n g
n n i d he o o -
F e b e c i -
e t a 's tv a t
n i r o d r c t s n -
i i
l o s f e n e o n i m
t ai f a v vr e mi t c
i r
u s e t
o e a c v s .
l a a p n r e i y wuk o t k d s r C
I l e s c a pi n a c f o
f p nb o ml e b n
o midt e i nd e r n e e y a a r fe r of -
r x e F f o s t
t e p r F a _
a d e _
e P P p I
I e OP m n - - e - - o m O N N __
u - - - y S dp na Eom -
mCmoc oin CUA
r i
o s
v a
l e h n n p e o s b io n m a
n r l t i
t i
o x e a a a nn u t e c i t n o n a f o o t i
si ml a e u y c c a
s r e c v mv l t a u pf e oi s t
i d o mrd l s e i l
a n i pf no a s v e d nsr e n n g e
r a u e n i _
s s i o n t
n c s
r p
f o e r go d i a n te rt c i i t e t o s s e a t pi t e o a e r e min n d c np e o s wtao ta f i
R d c r t r te n r s i e r s n e n ie s e e te n o n;h t s n pd f id e i
o o l ai n e mie r c vd d ef i
e dh t c i g a s k tat e i et a s nd o e at o a o oe n l md e u r s s n rU aN v o rLIsd fid r l
a o e e i v
t c P -
MP - -
nl u K a o c Ci n F
y n
a p
m o
C gUi A
m o
c n
i
1 s
n _
o i _
t .
c A i s
v e e i
v L t
c W.
e r
r o
C y
n a
p m
o C
m o
i c
n U
A
l d e g t
e n n a n i s
c o i i s a n r e r _
u p o m d t _
m e l e .
o v b _
c l o a s v i c
n n l p
o s i p -
n i _
t a h t a o
t i _
t _
c i
t e w o n
c p g -
A x e i n t s _
t e _
e d e e e
v s nl hs _
a e snr i
t n n m t c o nn e ce _
e i
t oos c ac _
a n n t
r a i t r f r c a e o o o o
i n mp t c yc _
C u rl ol e Ct e a c m f no a Rfa _
m I t F Ns o - - -
C
- y dp an Eom _
mCcmo _
oin CUA t
i g
i n
n i o -
a t t
r d t s
, e nr d i
eos v miv o r
n r pl o e ipr e s n s
vu n n n o o ns io ss i
ee sr t kn .
ee sp c rl i
e g y A ot v e
wsoibr i ho n r sf a ci s i
v ul ol ad av t i c n or cep c soa e .
nt s l au r odr us r cee g dn o g yd i C i n t ia ev f o n i va i t
n ar pm a dr _
i S I nec _
a .
r - -
T .
- y n
da p Eom mCocm _
oin CU A L
g i
n k
r a
m h
c n
e e s e r e b o r n t t t a
u s
s s
i o i m n o e t i g
l c c c m o o i F r A C r
o I P
ps e g F n tn i
v i n I P
f o i o e t n o s t c e s e c m e e r
t k n a e v r s s c c e e o r e S a v vr o c t b i
t c ip t
C o n d r
p e
v e e f f
e cm e
ri t E F E rd t
i
- - - o n P Ca
- - y dp an Eom mCmoc oiUn CA _
L
f _
o t
s y n t
n e e o f a m i
t s e -
c a
a tn r t
c ge o e
p i nmn nn e f
i
~
C x i a o r r d s I t i n _
t nv n o n i a e n a i t
a e n v m mk or i o r e
e t o tas s g
a d e s wci nb o o
n t u ni l a t i
o ut a a n
M mimt c c o ms o n me op s
r Cc o Ce Px e y dp na
- - - Eom mCcmo oiUn CA t
e
. 9 y
e r m r i e _
P t
r e
v S.
O J. -
y _
n -
a -
p m
o C _
m -
o -
i c
n U _
A L
C f o
e
- R e g N s d a h u n t u
t e a o i
h e w t n o t o i t n t t
u d t e e o e s u e r t i
i s d g "
m n n s
a t o
i l
o c i o
n y t e U i s
l i
r e
m a
r e
t a
u e n a i t p q o r o e m i m e d i
t t
a i
r p
vo t n a r t S
a s e s l e 12 l p
i v n o
i e n n2 e n g
O r y
s use o8 s
f a
s i
f f
B ei t r r e a mie v t n t s
t a ii t
pt e o s t f e "e e ar c oL t
c n o
mv v l c a e i i s od oi r pmi t t e r e mia er r s ht t t e e ga nnir y dp na vc i l oe o e v Op OexHe r CGNo Eom
. * * * *
- mCmoc oin CUA e
t a 9 8 9 _
s 9 9 9 _
n r
9 9 9 1
1 1 e r l c e hc i
r n b r p o _
c ma A c M-e e m e - n D ni to _
i t
r o e -
a i
v t t e a o 8 s m d u mr -
n f 9 q r o _
u o9 e fo f
n n1 r n o ore i g _
r g
i t Ci gi n ab k uot R n y c
l a c Nifyi r -
a vO e t o f i
r a -
B n n de l
a l
c _
a o d c d _
di e e t a
nd e d
=
o t i _
t p s v s t eS s e o u n r u pr e .
qo q e r d e d -
r yE r -
E CB mC m y Reh o R o dp na Nt CNC Eom _ -
- * *
- mC m o
c oin CUA L
e i
m t
r e
v eO i
t mrot iSk i2
- I tlN i i r
e a l
- ^
ver Op fO o r e t o
s c )
Uae 7 2
(
)
s )
l R )%
9 4 f a
r e
n u
4 0
(
p 8 2
(
r d
n) a% k u
e 9 )
e v
s 9 i
M a
(1 l
o ) )
9 %nr 9 u % )% gr 1
h i
b p
e
%/ n
- 6. io 1 T)
%( 9. uinP) 0( a 1 t 6
4 _
k h 7 g (4 t i
( f i ot d
c%sd e
s e n n l
r S 01 l r c i4 v e y o kc pi(
on r n W de.oB n( a pl d e( 1 i e s
S as uR a p .
ed i u S n f- sB e g m go be cakorg rr so ot- nk oL n G t
o ma n e u c ia n C _
OEVWEP OS UT i -
i r -
m o
E9EGOEBOOE i c
n U
A L
q.
e 4
i m M t
r e
M v %
4 O $ d s
nr o 4 F
i o
r e
p ot g e i
t a % A v t g
a t
are l k
y u o
e S p %e t
e e
t a
c W
nO i
d 4+ O n V
i R
or s _
S a r
yt o $
- +
E e r
a _
B c
~ d _
a e
% d h
e a
S _
R ##
r _
o M .
i n 4 _
e V S $
4 y n
a 0
4 5
3 0
3 5
2 0
2 5
1 0
1 s
o4 C
o p
m ige]hejl58gE4 m o
i c
n U
A L
g# .
g i , -
4 e %
0 m
4 -
A i -.
t #
r $ s e
d
- o nv oO % g i
e r
e p
% g _
i v a t r A t _
a o y u t
S t
a %
0 l
k e
e t o
e a
c r W ne i
4 O S
d n
o p r
- +
t
- p N
5 i
s a
e yO ##
1 d
r a
H o r % d a
e h
t c % S a
e 4 R 0 4
/
% y 4
n a
p 9
4 3 5 0 3
5 2
0 5 0 5 o s m
2 1 1 o
C t E y 8*g[=OgE4.
m o
i c
n U
A L
r _
ton ao ri t e u _
pb -
Oi tr O R
s r s8 S l
t oi ) 9 d a
u -
i v
c1 9 i d
a e1 I n
e 0 Rm 4
i t
r r o e n v i
S eO E
0 0 y 0 n 8 a p
m o
C m
o i
c n
U A
L
n o
ri t
ot u ,$1a fus;$:
S ab ' _
ri s e tr O R
ps8 l a
u Oi D99 d i
i d
v r I n .
t oe1 }g ? A B hi ,"" ,.l p:
8 2
c m ai t e r Re v O
0 0 0 0 0 0 0 0 0 0 y 0 0 0 0 0 0 0 0 0 n 9 8 7 6 5 4 3 2 1 a p
$C5$%o a.5z m o
C m
o i
c n
U A
L
z e
r n a e i
o ) m et r a %
5 i
t r
uiz 7 e v
d r e o (~ o ch s s f e ot r u n e n o pal i o g .
m e/nd e i t n _
i t v oi a i r s r i t i u i z o l e a ta g r i t o r
v g .
r u e o n t t
sl minht s o n O
i nvr ait t e ud m o _
f i e e e a o / c myr t _
o v m o
i e r n e -
e e l
o d
a o g c a mep m i m .
s nf i t t s r r i eidv e o - r g e s e t
n i t
mre e c
t e ot e
va e s
s vo o r p x e
c a f u aG e C e u vs f o o z o t o g s r in tyt o dGi e d n e o r id uN n
r a
oi r i r u r e s i
s d i
t uP Dji ot t n o n t
a q - - a S r e
Mical mo r a c t S y n
dp a Eom mComc oin CU A i
\l { -
t e n l
a k i m p i
nt r g f l e e n l
e yv ri t a c e s no s a e af i
miy sf t o o p l
e tr m t i s i r dt n u n t e n o o v a ded c n O nin a ot r
ui s f
i t
os o e o a nt n ta u s ud e t
c l i ad e vh t e a v sl e e s m p a i i t
t i t n nr hi o oev m gvi i s
u o iit I
r c a s t y e a e r l c dn t vt p n o a 6
f e Ono e c te a r nl a sme la uy a S e s e r l
c e t we us s e v def ae qt Nab Oa s y
- dp an Eom mCcmo oiUn CA l u
. c s
k r y a l e
m n _
a e t R S _
g G.
i n
s H.
l o _
C -
y dp an Eom _
mCmco oiUn _
CA _
, L