ML20236E693
| ML20236E693 | |
| Person / Time | |
|---|---|
| Site: | Sequoyah  |
| Issue date: | 10/17/1987 |
| From: | Leslie J, Walters R TENNESSEE VALLEY AUTHORITY |
| To: | |
| Shared Package | |
| ML20236E191 | List: |
| References | |
| 20400, NUDOCS 8710290317 | |
| Download: ML20236E693 (186) | |
Text
- _-. _ _
1 TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 I SPECIAL PROGRAM REPORT TYPE: SUBCATEGORY REPORT FOR REVISION NUMBER: 2' ENGINEERING TITLE: . ENGINEERING ORGANIZATION AND Page 1 of S1 OPERATING PROCEDURES REASON FOR REVISION: 1
- 2. Revised to incorporate SRP and TAS comments and add Attachment C '
-(References).
PREPARATION PREPARED lBY-$YA $ Wb >#
SIGN
/o-/74 7 DATE 1
V REVIEWS
-C IEH COMMITTEE-
'/ '
JY' o.
N/l]!b] ~
SIGN URE // ~ ~ OATE TAS: ;
SIGNATURE DATE CONCURRENCES CEG-H _
SRP:
SIGNATURE DATE SIGNATURE" DATE APPROVED BY:
ECSP MANAGER DATE MANAGER OF NUCLEAR P0HER DATE CONCURRENCE (FINAL REPORT ONLY)
SRP Secretary's signature denotes SRP concurrences are in files.
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400
[. REVISION NUMBER: 2 SPECIAL PROGRAM
). Page ES-1 of 2 k
l EXECUTIVE
SUMMARY
4 Subcategory Report 20400 summarizes and evaluates the results of 27 element evaluations prepared as part of the Engineering _ category of the Employee ,
Concern Special Program. The element evaluations cover the subcategory l
l Engineering Organization and Operating Procedures and address the 36 employee l concerns that cite perceived deficiencies and inadequacies in the TVA 1 engineering- organizational structure or operating procedures (design process),
as well as the cuality of the output documentation. The employee concerns identified 123 issues, which are addressed in the element evaluations and !
which are related to TVA's four nuclear plant sites. !
The evaluation team examined the 123 issues raiseo by employee' concerns and-evaluated their relevance to applicable regulations, requirements, and accepted industry standards. The team found that 72 issues required no i corrective action and that 51 were problems of which TVA was already aware and ;
was in the process of resolving. Only one new corrective action was required and that was to resolve a peripheral finding identified during the ECTG evaluations. .
This report identified deficiencies in TVA's organizational structure in that responsibilities for nuclear activities were divided among several departments that reported to separate managerial structures. Design change procedures and
. procedures to control' vendor documents were not f ollowed, were sometimes cumbersome and lengthy, and sometimes did not provide information or instructions to accomplish tasks as they should be 'done. Also, design reviews i were not always conducted when needed, nor were they sufficient to identify design specifics that should have been changed. ,
The substantiated issues indicate the need f or increased and continued management: attention to the engineering design processes and for increased Division of Nuclear Engineering (DNE) involvement in plant modifications.
Engineering Assurance (EA) auditing will provide some assurance of compliance with .various practices by providing feedback to management on engineering perf ormance. Monitoring of the engineering products on a day-to-day basis is i the responsibility of engineering line management. The latest DNE procedures ] I are augmented by site-specific procedures that, when properly f ollowed, ~
provide a means to mitigate many of the engineering design process problems of the past. Management attention should also be directed to provide adequate staffing to allow careful review and checking of the engineering work and the design documents as they evolve. The organizational changes that have been made, especially to strengthen the Branch Chiefs' technical review responsibilities and the Quality Assurance and EA organization, provide a reasonable means to monitor the engineering design process and adherence to procedures.
- A review of TVA nuclear performance plans (NPPs) at the corporate level and for the Sequoyah (SQN), Browns Ferry (BFN), and Watts Bar (WBN) nuclear 28110-R25(10/15/87)
i TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM REVlSION NUMBER: 2 Page ES-2 of 2 l
\
l plant sites reveals that TVA recognized problems and deficiencies in the nuclear organizational structure and in the engineering operational procedures. Currently, there is no site-specific NPP for the Bellefonte ,
plant, which is several years away from completion of design and -
construction. The NPPs describe the deficiencies and the corrective acticas at the corporate level and at the plant sites for SQN, BFN, and WBN.
Of significance are the consolidation of all engineering design functions into a single organization with a single set of nuclear engineering department procedures (NEPs) and the strengthening of the quality assurance (QA) program. These procedures are to be augmented by plant-specific engineering procedures. The corrective actions described, when fully implemented, should ;
help to resolve the identified problems and help to prevent their recurrence.
The collective significance of the findings is that if the organizational and procedural changes had not been implemented, the mismatch between the plant configuration and the engineering drawings and other documents could have ,
i persisted and could have resulted in an engineering design or plant operating error.
The grouped evaluation at the subcategory level d-id not find an.y new or broader issues requiring attention. The causes identified and other evaluation results are being reexamined from a wider perspective during the Engineering category evaluation.
9;, -
1 4
2811D-R23 (10/15/87) 3
1 Preface, Glossary.'and' List'of Acronyms, for'ECTG Subcategory Reports I HISTORY OF REVISION ~
HEV
-NUMBER PAGES REVISED REASON FOR CURRENT-REVISION
- - - =
3 i To clarify that one or more _ ji attachments will help the reader. )
' find where's particular concern I is evaluated f i
-i
~
1 q
.j i
S i
I 9
L l
-TVA EMPLOYEE CONCERNS . REPORT NUMBER: '20h00-SPECIAL PROGRAM FRONT MATTER REY: '3 PAGE l'0F viii-3 o
Preface _
This subcategory report is one of a series of reports prepared for the
- Employee Concerns Special Program (ECSP) of the Tennessee Valley Authority (TVA).,'The'ECSP and the organization which carried out the program, the Employee. Concerns Task Group (ECTG), were established by TVA's. Manager of
. Nuclear Power.to evaluate and report on those Office of_ Nuclear Power (ONP)_ 1 employee concerns filed before February 1.-1986. Concerns _ flied after that. 1 date are handled by the ongoing ONP Employee Concerns Program (ECP).
The ECSP. addressed over 5800' employee concerns. Each of the; concerns lwas s' formal, written' description of a circumstance or circumstances that an- l employee thought was. unsafe, unjust._ inefficient, or inappropriate. ' The' !
mission'of the Employee Concerns Special Program was to-thoroughly !
investigate all issues presented in the concerns and to report the results of-those' investigations'in a form accessible to.ONP employees,.the NRC, and the general public. The resvits of these investigations are communicated.
by four levels'of ECSP reports: element,. subcategory, category, and. final.-
Element reports, the lowest reporting level will be published only.for-
. those concerns _directly affecting.the restart of Sequoyah' Nuclear Plant's-reactor unit.2. An element consists of one or more closely related issues. 'An issue is a potential problem identified by ECTG during the 1 evaluation' process as having been raised,in one or more concerns.. For 1
' efficient handling, what appeared to be.similar concerns were grouped into -
elements early in the program, but. issue definitions emerged from the '
evaluation process itself. Consequently, some elements did include only one issue, but often the ECTG evaluation found more than one. issue per element.
Subcategory reports summari'ze the evilurtion of a number'of elements. 1 However, the subcategory report does more than collect element level evaluations. The subcategory level overview of element findint,s leads to )
an integration of information that cannot take place at the element level. -)
This integration of information reveals the extent to which problems l
. overlap more than one element and will therefore require corrective action j for' underlying causes not fully apparent at the element level. J To make the subcategory reports easier to understand, three items have 'een b placed at the front of each report: a preface, a glossary of the terminology unique to ECSP reports, and a list of acronyms.
Additionally, at the end of each subcategory report will be a Subcategory Summary Table that includes the concern numbers; identifies other
- subcategories that share a concern; designates nuclear safety-related.
4 safety significant, or non-safety related concerns; designates generic applicability; and briefly states each concern.
Either the Subcategory Summary Table or another attachment or a combination ,
of the two will enable the reader to find the report section or sections in l which the issue raised by the concern is evaluated.
E ,
. .)
TVA EMPLOYEE CONCdRNS . REPORT NUMBER: 20400' p' SPECIAL PROGRAM PRONT MATTER REY: 2 PAGE'il 0F vill
.The subcategories are themselves summarized in a series of eight category reports. Each category report reviews the major findings and collective- ;
significance of the-subcategory reports in one of the following areas:
) management and personnel relations Industrial safety U L . construction l
{
material control l-
- operations quality assurance / quality control-i
- welding engineering 1
A separate report on employee concerns-dealing with specific contentions of intimidation, harassment, and wrongdoing will be released by the TVA Office j of the Inspector General. i
.1 Just as the subcategory reports integrate the information collected at the I element level, the category reports integrate the information assembled.in l all the subcategory reports within the category, addressing particularly i'
the underlying causes of those problems that run across more than'one subcategory. l
'A final report will integrate and assess the information collected by all 1 of the lower level reports prepared for the ECSP, including the Inspector General's report. I For more detail on the methods by which ECTG employee concerns were evaluated and reported, consult the Tennessee Valley Authority Employee Concerns Tast Group Program Manual. The Manual spells out the program's l l'
objectives, scope, organization, and responsibilities. It also specifies l the. procedures that were followed in the investigation, reporting, and l closecut of the issues raised by employee concerns.
t.-
i l
I i
i l
)
I L >
1 l
L.__m___ _ _ _ . _ _ _ _ _ _ _ _ _ '
_7 ,
q 4
I o
1 1
! ITA EMPLOYEE CONCERNS ' REPORT-NUMBER: ~20400' SPECIAL PROGRAM l FRONT KATTER REV: 2- -l
~
PAGE'111 0F vill !
ECSP GLOSSARY OF REPORT TERMS * ,
'l
', classification ~of' evaluated issues the evaluation of an issue leads to one of lI
- the-following determinations-1 i
' Class A: : Issue cannot-be verified as factual
.i' Class B:-
Issue is factually accurate, but what is described is not a-problem (i.e., not a condition requ' icing corrective action)-
C1'ss a C: Issue is factual and identifies a problem, but corrective action-for the problem was initiated bstore the evaluation of the issue ,
was undertaken -l
~
o Class D:- Issue is factual and presents a problem for which corrective- 1 action has been, or is being. taken as a result of an' evaluation- q Class E: A problem, requiring corrective. action, which was not' identified by an employee concern, but' was ' revealed during the ECTG
-evaluation of an issue raised by an employee concern.
collective significance an analysis which determines the importance and ,
consequences of the-findings in a particular ECSP report by putting those findings in the proper perspective.
' concern (see " employee concern")
corrective action steps taken to fix specific deficiencies or discrepancies revealed by a negative finding and, when necessary, to correct causes in order to prevent recurrence.
~
criterion (plural: criteria) a basis for defining a performance, behavior, or quality which ONP imposes on itself (see also " requirement"). -
element or element _ report an optional level of ECSP report, below the
. subcategory level, that deals with one or more issues, employee concern- a formal, written description of a circumstance or circumstances that an employee thinks unsafe, bnjust, inefficient or ,
1
[
inappropriate; usually documented on a K-form or a form equivalent to the l
K-form.
4 e
- TVA EMPLOYEE CONCERNS REPORT NUMBER
- 20400 l' .SPECIAL PROGRAM l FRONT MATTER REV: 2 l l
L PAGE iv 0F vill l-evaluator (s) the individual (s) assigned the responsibility to assess a specific grouping of' employee concerns.
1 i
findings includes both statements of fact and the judgments made about those ,
facts during the evaluation process; negative findings require corrective action. '
issue a potential problem, as interpreted by'the ECTG during the evaluation process, raised in one or more concerns.
I K-form (see " employee concern")
requirement a standctd of performance, behavior, or quality on which an evaluation judgment or decision may be based, root cause the underlying reason for a problem.
' Terms essential to the program but which require' detailed definition have been defined in the ECTG Procedure Manual (e.g., generic, specific, nuclear
. safety-related, unreviewed safety-significant question).
t
+
I t.
(
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM FRONT MATTER REY: 2 PAGE v 0F vill Acronyms AI Administrative Instruction AISC American Institute of Steel Construction ALARA As Low As Reasonably Achievable ANS American Nuclear Society ANSI American National Standards Institute ASME American Society of Mechanical Engineers ASTM American Society for Testing and Materials AWS American Welding Society BFN Browns Ferry Nuclear Plant BLN Bellefonte Nuclear Plant CAQ Condition Adverse to Quality CAR Corrective Action Report CATD Corrective Action Tracting Document CCTS Corporate Commitment Tracting System CEG-H Category Evaluation Group Head l CFR Code of Federal Regulations CI Concerned Individual CMTR Certified Material Test Report COC Certificate of Conformance/ Compliance DCE Design Change Request DNC Division of Nuclear Construction (see also NU CON) 9 m
9 TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 I SPECIAL PROGRAM ;
FRONT MATTER REY: 2 PAGE vi 0F vill
.1 DNE Division of Nuclear Engineering
.DNQA' Division of Nuclear Quality Assurance DNT Division of Nuclear Training DOE Department of Energy.
DP0 Division Personnel Officer DR Discrepancy Report or Deviation Report ECN Engineering Change Notice
- ECP Employee Concerns Program i
ECP-SR Employee Concerns Program-Site Representative ECSP Employee Concerns Special Program
]
- ECTG- Employee Concerns Tast Group EEOC Equal Employment Opportunity Commission l
EQ Environmental Qualification . .
EMRT Emergency Medical Response Team EN DES Engineering Design ERT Employee Response Team or Emergency Response Team FCR Field Change Request
! FSAR < Final Safety Analysis Report FY Fiscal Year GET General Employee Training HCI Hazard Control Instruction g, HVAC Heating, Ventilating, Air Conditioning i
II Installation Instruction INPO . Institute of Nuclear Power Operations IRN Inspection Rejection Notice i_---,-----------a- -- --
I ^
- f TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM .
FRONT MATTER REVi 2 7
PAGE vil 0F viii '
L/R Labor Relations Staff '
M&AI Modifications and Additions Instruction MI Maintenance Instruction -
MSPB Merit Systems Protection Board ,,
MT Magnetic Particle Testing NCR Nonconforming Condition Report NDE Nondestructive Eranination NPP Nuclear Performance Plan NPS Non-plant Specific or Nuclear. Procedures System RQAM Nuclear Quality Assurance Manual 4 NRC Nuclear Regulatory Commission r , . <
NSB Nuclear Services Branch NSRS Nuclear Saf$ty Review Staff NU CON Division of Nuclear Construction (obsolete abbreviation, see DNC)
NUMARC Nuclear Utility Management and Resources Committee OSHA Occupational Safety and Health Administration (or Act)
ONP Office of'iluelear Power OWCP Office of Workers Compensation Program PHR Personal History Record PT Liquid Penetrant Testing" b QA Quality Assurance 5, QAP Quality Assurance P;ccedures '
QC Quality Control QCI Quality Control Instruction
.(.
.e
~
- li , . * :
v> . f ' ..
- g. _9r TVA EMPLOYEE COWCERNS i,' .. f REPORT NUMBER: .20400 SPECIAL PROGRAM u-FRONT MATTER REV: 2
- Q. [ PAGE vill 0F viii .
J. .
(
QCP . Quality Control. Procedure ,
., ~{
- j QTC Ouality Technology Company
! -l RIF - Reduction in Force )
l RT Radiographic Testing ; .
SQN Sequoyah Nuclese Plant p- '. 5 [.
t SI Surveillance Instruction 4
SOP. Standard Operating Procedure l V
SRP- Senior Review Panel SWEC - Stone and Webster Engineering Corporation
.g TAS Technical Assistance Staff.
e I,
T&L Trades and Labor f
/- TVA- Tennessee Valley Authority
, e'
~
TVTLC- Tennessee Val y Trades and Labor Council" "
UT Ultrasonic Testing VT- Visual Testing , , p. -
WBECSP Watts Bar Employee Concern Special Program (
4' y. WBN Watts Bar Nuclear Plant WR Wort Request or Wohk Rules ,
Workplans
'l ,
WP -<
f:. f ,
t.
,/ -
t ) _.
'}
t q ,
y .- (
k l
l- q
( L 1
f ,? s 4
l i ,
L. N: _ . _ - _ _ _ . _a . . _ _ _ _ _ _ _ _ _ _ -
4
~'l% ,
' /
-TVA' EMPLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM REVISION NUMBER: 2
' i d', - Page 2 of 51 l i "
a._. L '
l
, ,/
4 a \ \
1 -Q k
CONTENTS
}
l il14, -
>y j j
SectioM i .
Paae
) v s g Eiequ. tive $,im.rsy ES-1
]
3 Preface n, i -:
t ECSPG1csarycpReportTerms lii i Acronyms v i I
fj 1 Introducti$9 '
3 '
,s !
Dllb 2 Summary cf Issues / Generic Applicability 4 !
t 3 Evaluttion' Process 7 4 Findings 9 I t
- 5 Corrective Action 1 ' 35 i 10 Causes (1 40 o
s , i l r7 Collective Significance 41 o V
'A Glossary N;plement foi'.the Engineering Category 49 j
Attachtrang , -l C .
, q t:a , l f." A Employee Concerps' for Subcategory 20400 A-1 j i
'l B Summary of Issues, Findings, and Corrective Actions B-1 i
,s for Subcategory 20400
~) C References C-1
, y,,
1
'}
s
'\ '
TABLES
(.
S. Table a Pace 1 Classification of Sindings and Corrective Actions," 44 l
2 Findings Sumary 'i 46 4
3 Matrix of Clements, Corrective Actions, and Causes 47 v' fx'x v v~'
i 23iiD-RZ4;
\ (10/15/87) \
u ;
- ~
c . _ - - _
TVA EMPLOYEE CONCERNS REPORT ~~ NUMBER: 20400 SPECIAL PROGRAM: REVISION NUMBER: 2.
Page 3 of 51
- 1. INTRODUCTION' l
. ~This subcategory report summarizes and evaluates the results of the ECSP
, . element evaluations prepared under Engineering Subcategory 20400, Engineering Organization and Operating Procedures.
The employee concerns provide the basis for th_e element evaluations and are listed by element number in Attachment A. The plant location where the concern was originally identified and.the applicability of the concern to
-other TVA nuclear plants are also.shown.
.The employee concerns cite perceived deficiencies in TVA's organizational structures, interdepartmental communications, methods of, handling design review, and engineering design processes. The concerns also cite perceived deficiencies in the procedures and other documents that govern the engineering design change and plant modification processes. !
Between 09/73 and the present time, three different sets.of engineering department procedures have been used to address such requirements as checking, review. approval, issue and revision of engineering drawings and i documentati_on. -The deficiencies ~ described in this subcategory report . relate to complicated and ineffective procedures that resulted in poor review cycles, divided responsibilities, poor test and installation specifications, drawings lacking in engineering detail, poor design review and verifi::ation requirements, and illegible vendor information. i Revision 8 of TVA Topical; Report TVA-TR75-1A, which is the Quality Assurance Program Description for the Design, Construction, and Operation of TVA Nuclear Power Plants, was the revision available when the element evaluations for this <
subcategory were written. Revision 9 of the Topical. Report has been assessed, !
Jbut does not alter the findings and. conclusions of these evaluations.
The evaluations are summarized in the balance of this report as follows:
o Section 2 -- summarizes, by element, the issues stated or implied in the employee concerns and addresses the determination of their generic applicability l
- o. Section 3 -- outlines the process followed for the element and subcategory evaluations and cites documents reviewed l o Section 4 -- summarizes the findings by element, and identifies those negative findings that must be resolved
- o. Section 5 -- highlights the corrective actions required for resolution of the negative findir.js cited in Section 4 and relates them to each element and to each plant site 28110-R26 (10/15/87) t I
l REPORT ~ NUMBER: 20400 TVA EMPLOYEE CONCERNS REVISION NUMBER: 2 SPECIAL' PROGRAM L Page 4.of 61' I
Section 6 -- identifies.causes of the negative findings
~
o l' o Section 7 - assesses the significance of the negative findings o' Attachment A -- lists, by element, each employee concern . evaluated in the subcategory. The concern's number is given along with t
notation of any other subcategory with which the concern is shared.
and the plant sites to which it could be applicable. The concern is quoted as received by TVA, and is characterized as safety related (SR), safety significant (SS) or not safety related (NO)
!^
o Attachment B -- contains a summary of the element-level evaluations. Each issue is listed, by element number and plant, along with its ' corresponding findings and corrective actions.. -The reader may trace.a concern from Attachment A to an issue in Attachment B by using the element number and applicable plant. .The f
l reader may relate a corrective action description in Attachment B to !
causes and significance in Table 3 by using the CATD number which appears in Attachment B in parentheses at the end of the corrective action-description.
The term " Peripheral finding" in the issue column refers to a finding that occurred during the course of evaluating a concern but did not stem directly from a employee concern. These are classified
- as "E"-in Tables 1 and 2 of this report o Attachment C -- lists the references cited in the text
- 2.
SUMMARY
OF ISSUES / GENERIC APPLICABILITY The employee concerns listed in Attachment A for each element and plant have been examined, and the potential problems raised by the concerns have been identified as 123 separate issues. Evaluation of these issues is presented in
.i 27 element evaluations.
However, some All of the elements were evaluated for the four nuclear plants. ,
of the individual elements were combined with others at certain plants to '
f acilitate evaluation, review, and preparation of corrective action plans.
For example, elements 204.1, 204.2, and 204.8 had individual element evaluations prepared for SQN, while they were combined and addressed Table 1 of thisunder report element evaluation 204.1 for the other three plants.
shows which evaluations addressed each of the elemen3s at each of the plants.
2.1 Generic Applicability
}
Nine employee concerns, of the total of 36 addressed in Rather, this subcategory, they are are not generically applicable to all four nuclear plants.
related to site-specific organizations, components, or situations, and, thus, l
L are. addressed..in the element evaluations only on a site-specific basis.
i 2811D-R26 (10/15/87) t
- - - _ _ _ _ _ . _ _ _ _ _ _ i
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM REVISION NUMBER: 2 Page 5 of 51 Element 204.1. Concern WI-85-047-001 dealt with.the. lack of a timely response
.from engineering for instrument set point data for a specific WBN system.
Element 204.4. Concerns IN-85-414-003, EX-85-085-002, and IN-85-276-002 dealt with possible shortcomings (e.g., specific instruments not shown on a drawing) in specific WBN engineering drawings.
Element 204.5. Concern I-86-114-BFN dealt with an Office of-Engineering (0E) review of the staffing level and adequacy of the training of engineering-personnel at BFN to handle the known BFN workload.' Concern HI-85-077-N02
' dealt with documentation concerns regarding original procurement specifications for BFN. Concern XX-85-126-001 dealt with changes being made to vendor drawings specific to BLN without prior approval of the vendor.
Element 204.6. Concern WBP-85-018-003 dealt with a specific group of engineering change notices (ECNs) for WBN. Concern OE-QMS-5 questioned a decision by the BFN Engineering group management regarding handling of ECN data sheets at BFN per the BFEP procedure.
The remaining 27 employee concerns were generically applicable to all four nuclear plants, and they were addressed accordingly.'
2.2 Summary of Issues The issues evaluated under this subcategory are grouped by element, are summarized below, and apply to all four nuclear plants unless' otherwise noted: I 1
o 204.1, Organizational Structure - TVA's organizational structure is unwieldly; there are too many people in the review cycles,' too many ,
procedures, and too much paperwork. WBN field requests for '
technical information from Engineering are not answered in' a timely manner.
o 204.2, System Desian Responsibility - Individual engineers are not knowledgeable of, or responsible for, overall system design.
o 204.3, Field versus Desian Office Responsibility - TVA leaves too many technical decisions regarding pipe supports and hangers up to craft personnel.
o' 204.4, Desian Document Completeness /Adeouacy - There are deficiencies in engineering drawings. TVA designs are not developed well enough and do not adequately encompass constructibility, maintainability, testability,andoperabilityrequirements. TVA l general construction specifications (G-Specs) are often inadequate, l and drawings do not always show all the details or represent design requirements.
9 i
2811D-R26 (10/15/87) l l
\ \
L____ . :
-ij TVA EMPLOVEE CONCERNS REPORT NUMBER: 20400 j SPECIAL PROGRAM REVISION NUMBER: 2 Page 6 of 51 o 204.5, Desian Review / Verification - Various engineering documents at i TVA, including vendor calculations and designs, are not f appropriately reviewed under an adequately controlled design process. Second independent technical reviews are not completed, and some reviews are not performed by qualified personnel. There is i inadequate staffing of engineering personnei at BFN, which could
. result in insufficient review of engineering documentation; design engineers did not document the original specifications at BFN; and changes were made to BLN vendor _ drawings without vendor approval.
o 204.6, ECN Process -' Engineering change notices (ECNs) are not i written with sufficient information and are not properly processed, tracked, or closed out. Consideration is .not given to the impact of the change on other disciplines, documents, and construction work.
o 204.7, Vendor Docaents - Vendor manuals in use at the plant sites
- are not at the correct revision level, and vendor drawings are of poor quality.
1 l
o 204.8. Communication and Interf ace Control - Communication and interf ace control within Engineering, and between Engineering and other organizations, are ineffective.
o 204.9, Use of Reverse Prints - Unit 1 prints marked " opposite hand" are being used for unit 2, which makes work more confusing for l engineering and construction personnel.
The nine issue summaries above (one for each element) deal with presumed deficiencies in the Engineering organization and the design process and 4 l procedures. More specifically, four of the elements contain issues that are
! concerned with the overall engineering process (elements 204.1, 204.3, 204.5, and 204.8), three deal with design process and design changes (204.2, 204.6, .
and 204.9), and two pertain to design output documentation (204.4 and 204.7).
As the.following sections show, five of the issues summarized by element above ,
were found to be valid and require corrective actions (204.1; 204.5, [for BFN l only]; 204.6; 204.7; and 204.8). One of these involves establishing l engineering interfaces and improving organizational procedures, three involve engineering verification procedures and design change control, and one involves quality and dissemination of vendor documentation.
1 Each issue examined within the element evaluations is stated fully in Attachment B, which also lists the corresponding findings and corrective ;
actions that are discussed in Sections 4 and 5 of this' report.
l 28110-R26 (10/15/87) l 1
i TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM REVISION NUMBER: 2 l Page 7 of 51 !
- 3. EVALUATION PROCESS This subcategory report is based on the information contained in the <
applicable element evaluations prepared to address the specific employee concerns related to the issues summarized in Section 2.
The element and subcategory evaluation process are discussed below. The references cited are listed in Attachment C.
3.1 Element Evaluation Process The steps listed below were followed to evaluate issues for each of the element evaluations.
- a. Defined issues for each element from the employee concerns.
Attachment A of this report lists the employee concerns addressed in this subcategory report. !
- b. Reviewed regulatory documents (Refs.1 through 8,15, and 16),
industry standards (Ref s. 9 through 14), TVA commitments (Refs.17 through 24), and design criteria (Refs. 121,122, and 123) to develop an understanding of the requirements of engineering organizational structure and operating procedures.
I
- c. Reviewed available transcript of NRC investigative interview (Ref. 209) to gain additional information regarding concerns listed in Attachment A.
- d. Reviewed TVA documents such as Quality Assurance Programs (Refs. 25 through 40), Nuclear Performance Plans (NPPs) (Refs 41 through 46),
Project Manuals (Refs. 47 through 57 and 120), Verification Programs (Refs. 58 through 62), Reports and Standard Practices (Refs. 69 through 105), and TVA Corpo' rate Commitment Tracking System (CCTS)
(Ref.106) to establish the responsibilities and practices related to the issues.
- e. Reviewed engineering department procedures (Refs.107 through 118) that establish organizational structure, design process, design j change interf ace and communication between the design office and the field, system design responsibilities, TVA practices for compliance I to procedures, vendor design document control, and design review and l verification practices.
- f. Reviewed results of the program audits (Refsi 135 through 151) to determine practices followed by TVA to comply with procedures.
G e
2811D-R26 (10/15/87)
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM REVISION NUMBER: 2 Page 8 of 51 l 1
-l Additiona'l steps listed below were followed to evaluate the specific l element _noted. J l
- g. For element 204.3, reviewed applicable Conditions Adverse to Quality. <
(CAQ). documents (Refs. 132,133, and 134) in regards to indication i of equipment supports design input by craft personnel. j
- h. For element 204.4, reviewed Gene ~ral Construction Specifications j
(Refs.126 through 129) to assess the completeness- of specifications.
i
-1. For. element 204.4, reviewed appropriate number of design drawings .- i related to CAQ reports in the EN DES Data Base (Refs.131), to .i establish the severity of the problems prompting the re-evaluat 4 n of existing procedures in completing the design output documen:s.
- j. For element 204.4, reviewed an appropriate number of drawings for l completeness of specific technical design details.
- k. For element 204.5, reviewed equipment procurement packages (Refs.152 through 196) in regards to documentation of-specifications in the procurement packages.' .
- 1. For element 204.6, reviewed Division of Nuclear Engineering Design I Change Control Procedure NEP 6.1 and subsequent clarifications 1 (Refs. 53, 57, and 109), to establish the practices followed in the j control of design change documents (ECN etc.).
- m. For element 204.6, reviewed NRC staff evaluation of the Design Baseline and Verification Programs (DBVP)'(Refs. 215 and 216) to 1 determine NRC's acceptance requirements for plant modifications and l change control long term program. 1
- n. . For element 204.6, reviewed memorandum (Ref. 220) regarding TVA's coninitment of the design change process improvement program.
- o. For element 204.7, reviewed Engineering Department Procedures (Refs, 88,107,108,109,112, and 116) regarding the review and control of vendor documents,
- p. For element 204.9, conducted interviews (Refs. 237, 238, and 239) with Engineering, Construction, Craft, and Quality Assurance ,
personnel in regards to the issues. ]
l Using the results of the element evaluation process, the issues were evaluated l for the element and the findings and corrective actions were documented.
1 28110-R26 (10/15/87)
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM REVISION NUMBER: 2 Page 9 of 51 3.2 Subcategory Evaluation Process Subsequent to the element evaluation process, the steps listed below were followei to prepare this subcategory report.
- a. Tabulated all the concerns addressed by this subcategory report in Attachment A.
- b. Tabulated issues, findings, and corrective actions from the element evaluations in a. plant-by-plant arrangement (see Attachment B).
- c. Prepared Tables 1, 2, and 3 in this subcategory report to permit '
comparison and identification of common and unique issues, findings, and corrective actions among the four plants.
- d. Classified the findings and corrective actions from the element evaluations using the ECSP definitions.
- e. On the basis of ECSP guidelines, analyzed the collective significance and causes of the findings from the element evaluations. .
- f. Evaluated defined corrective actions to determine if additional actions are required as a result of causes found in step e.
- g. Provided additional judgment and/or information that may not have been apparent at the element level.
- 4. FINDINGS The full text of the findings from each of the 27 element evaluations is stated in Attachment B, listed by element number and plant.
The findings (including validity of the issues) within each of the elements
'are summarized in the following paragraphs. Minimum discussion is devoted to those . findings for which no corrective action is required, such as cases where the allegations were not substantiated by the evaluation, or cases in which the allegations were found to be true but the consequences are acceptable.
4.1 Element 204.1, Organizational Structure
4.1.1 Issue
TVA's managerial structure is unwieldly and cumbersome, wnich sometimes leads to confusion in the design process.
(Addressed as issue "a" for all plants, as s,hown in Attachment B)
Findina. To further assess the review cycle for ECNs and DCRs, the evaluation team reviewed EP 4.02 and EP 4.18 (Ref.107), OEP-il (Ref.108), and NEP-6.1 (Ref. 109).
A review of TVA audit reports and memoranda (Ref. 135, 216, and 217) discloses audit findings and recommendations which indicate that significant deficiencies existed in TVA's Division of Engineering Design (EN DES) managerial structure in 1984 and 1985. In late 1985, a corporate evaluation by INP0 reported the following finding which TVA accepted (Ref. 213) as valid:
2811D-R26 (10/15/87)
TVA EMPLOYEE CONCERNS . REPORT NUMBER': 20400 SPECIAL PROGRAM ' REVISION NUMBER: 2
'l
" Page 10 of 51 I
. " Responsibility and authority for the various Office of Nuclear Power - I organizations have not been clearly defined or sufficiently 'l communicated. 'As a result, there is confusion in the organization."
In the CNPP (Ref. 42) TVA stated that " responsibility ',~or various nuclear -
functional areas [ including engineering] was divided among several groups."
Investigations by TVA (Ref. 63)'and the Institute _of Nuclear Power Operations (INP0) (Ref. 213) confirm that until 1985 the responsibility for nuclear i i
activities was divided among several departments, none of which reported to a single manager.
This . issue was valid at the time the concern was raised.
4.1.2 Issue
Paperwork is excessive and passes through too many hands. '
too.many people are in the review cycle for engineering change notices (ECNs), design change requests (DCRs), and memoranda. j
~ ( Addressed as issue "b" for all plants, as shown in Attachment B) j Finding.- A review of TVA's engineering procedures (Refs. 107,108,' and 109) indicates review cycles for Engineering Change Notichs (ECNs) and. Design j Change Requests (DCRs) that are similar to those used by other engineering j
firms engaged in the design of nuclear power plants. To evaluate the validity of the allegation that TVA required too much paperwork and that there were to i i
many people in the design change review process, the evaluation team reviewed-investigativereportsissuedbysixgroups(Refs. 93, 75, 63c, 104, 204, 205, 206, 207, 69, 68, and 213).
None of these investigations found a design control problem at the plants or at TVA headquarters similar to those alleged.
1 This issue is not valid. - '
I
4.1.3 Issue
-Too many engineering procedures exist, and they need to be streamlined. ( Addressed as issue "c" for all plants, as shown in Attachments)
Finding. In 1981, TVA's NSRS reported (Ref. 63c) that "the f ailure to i consistently implement the EPs appeared to be due to a combination of factors l
. . . [ including] the large volume of procedures and inadequacies within the procedures." The NSRS recommended that EN DES policy, responsibilities, requirements, and guidance be systematically established in tiers of documents. i I
6.
k l
28110-R26 (10/15/87) !
l i -_ - - - - i
TVA EMPLOYEE CONCERHS REPORT NUMBER: 20400 SPECIAL PROGRAM REVISION NUMBER: 2 l Page 11 of 51 There were at least 18 volumes of EN DES discipline guides and standards, as well as four volumes of EN DES-EPs. The Engineering Procedures (EPs) were quite detailed and included many policy statements and QA requirements.
However, in 06/85 the EPs were replaced by a single " streamlined" volume of OEPs. Most of the Office of Engineering Procedures (0EPs) were in turn replaced by a single volume of Nuclear Engineering Procedure (NEPs) in 07/86. i The OEPs and NEPs were supplemented by site engineering procedures. l This issue was valid at the time the concern was raised.
4.1.4 Issue
There is a lack of timely response to requests for )
engineering information for WBN. (Addressed as issue "h" for WBN l only, as shown in Attachment B. This issue was unique to WBN, and l was not evaluated for the other three plants.) i Finding. This concern is supported by a statement from an ECTG Management and Personnel report (Ref. 97) which states that there have been numerous examples of construct'en production delays resulting from constructibility problems with design drawings, compounded by a lack of adequate or timely response by design engineers.
This issue was valid at the time the concern was raised.
4.2 Element 204.2, System Desian Responsibility
4.2.1 Issue
Responsibility and monitoring for overall system design is not assigned to a specific individual who is knowledgeable of all aspects of the system, including interf acing support systems.
(Addressed as issue "a" in element evaluation 204.2 for SQN and as !
issue "d" in element evaluation 204.1 for WBN, BFN, and BLN, as I
shown in Attachment B) j Finding. In 1973, EN DES was established and " system design engineers" who j were knowledgeable about the basic elements of the systems were assigned to the pr.ojects.
Within EN DES, the assignment of individual responsibility for system design and documentation was defined in the EN DES-EP manual (Ref.107), and very similar position descriptions appear in the Office of Engineering (OE)
Organization Manual (Ref.120). These position descriptions indicate that more than one engineer was responsible for the design and documentation of each system. The current NEPs (Ref. 109), which superseded the corresponding OEPs, eliminated the title " system design engineer." However, the function of designing each system by one or several engineers assited s by associate engineers was continued.
In 1984, INPO recommended (Ref. 68) assigning the responsibility for specific operatina systems to individual engineers. This recommendation was accepted by lVA, and systems engineering sections have been established at the 28110-R26 (10/15/87) _-
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 !
SPECIAL PROGRAM REVISION NUMBER: 2 Page 12 of 51 l
constructed plants. The engineers in these sections provide a single contact l point for system history, status, testing, and troubleshooting. l At SQN and BFN when the systems became operational, TVA located a systems engineering section, with individual system engineers, at the site to address l and resolve system problems. i At WBN and BLN, the responsibility for monitoring the complete system design, including interfaces with supporting systems, is assigned to the ONE project !
engineer and assistant project engineers on the design project. ,
Discipline teams are necessary to design the large, complex systems found in nuclear power plants. DNE staffs each nuclear power. plant design project with a project engineer, assistant project engineer (s), and discipline teams each !
having a lead discipline engineer, engineers, and associate engineers.
This issue is valid in that it is a true statement but it is not a problem.
4.2.2 Issues
With one person handling contract support, another mechanical, another controls, another electrical,etc., i responsibility is fragmented and quality has been affected.
(Addressed as issue "b" in element evaluation 204.2 for SQN and as issue "e" in element evaluation 204.1 for WBN, BFN, and BLN, as shown in Attachment B) ;
Findina. In 1981 and 1982, TVA internal memoranda (Refs. 222, 224, and 226)
' documented deficiencies in system design responsibility. However, the authors of the memoranda advocated assigning a scope of responsibility to various .
individuals working on a system, rather than total system responsibility for {
one person.
The current NEPs (Ref. 109), which supersede the corresponding 0EPs, govern I design control and provide for satisf actory coinpliance with regulatory design' ?
control requirements. They do not require that overall system design control ,
be assigned to one individual. While the actual design details of interfacing j systems is divided among the disciplines, the project engineer and assistant ;
project engineers are responsible for the overall quality and adequacy of i system engineering efforts. There is no evidence that the team design !
approach used by TVA detrimentally affected the quality of any TVA plant. l l'
The issue is valid in that it is a true statement. However, after reviewing the concern and considering the systems involved, the evaluation team concluded that it was not possible in the design stage,for individual engineers to be informed about all aspects of their sys' tem (s), and the ;
interfacing support systems.
l 4
! 2811D-R26 (10/15/87) l I _ _ _ _ _ _ ______-____a
L .j
. TVA EMPLOVEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM REVISION NUMBER: 2 I Page 13 of 51 .
4.3 Element 204.3,. Field versus Desian Office Responsibility
- 4. 3.1 - Issue: TVA leaves too many technical decisions to the discretion of the craf t personnel (e.g., hanger design).. (Addressed as issue "a" 3 in element evaluation 204.3 for SQN, BFN, and-BLN and as issue'"f" )
in element evaluation .204.1 for WBN, as shown in Attachment B).
Finding. The evaluation team found that SQN, BFN, BLN and other TVA engineeringprocedures(Refs. 107,108, and 109) are adequate and a circumvented approval process, as described in the issue, should not occur. A review of TVA audit reports (Refs.136 through 139), and discussions with cognizant personnel (Refs. 240 through 243) indicate a problem existed at WBN where procedures (Ref. 107,108,109 and 49) did allow the craf t to make limited adjustments during hanger installation.
In 01/85, a WBN (unit 2) field change request study by TVA (Ref. 233) found that about 51 percent of system 62 and system 63 hangers required FCRs. Of these FCRs, almost half were necessary because of drawing problems such as incorrect dimensions.
In 05/85, INPO found (Ref. 69) the following deficiericies in field programs -
necessary to supply technical guidance to the pipe hanger craftsmen: 1) Work packages were incomplete. 2) Constructibility reviews were not identifying many interferences and design errors, and 3) Field engineers were unavailable to resolve problems. ;
In 07/85, a Nuclear Safety Review Staff (NSRS) report (Ref. 63e) found that 3 "the 47A050 notes [ associated with the pipe support detail drawings] require frequent changes."
Finally, an Employee Concern Task Group (ECTG) report (Ref. 97) found that in an attempt to meet construction production schedules, the FCR process has.
occasionally been misapplied.
At BLN.the INP0 report (1984) states that'the pipe support installation ,
program in the field is effective in producing pipe supports that meet design requirements with' low rejections at inspection.
The issue is valid for WBN, SQN and BFN although TVA procedures do not authorize craft personnel to make design decisions and, engineering approval of field changes has been, and is, required at all TVA nuclear plants.
However, the evaluation team found no evidence to support the implication that ,
decisionsbythecraftswereresponsibleforanyprobigms. f l
i
. - . . ~ _
)
28110-R26 (10/15/87) 4 1
REPORT NUMBER: 20400 l 2
6 TVA EMPLOVEE CONCERNS SPECIAL PROGRAM REVISION-NUMBER: 2- l Page .14 of 51 jl j
i j
4.4 ~ Element 204.4, Desian Document Completeness - Adeauacy i
4.4.1 Issue
Engineering (EN DES) inadequately addresses and considers-construction, testing, operation, maintenance, and general industry practices in the design process. -( Addressed 'as- issue 'f a" for all plants, as shown in Attachment B)
Finding. TVA engineering procedures that have been in effect since 09/73 (EN DES-EP 4.25, OEP-06, and NEP-3.2) all state that construction, testing, operations, and' maintenance requirements, as well as codes and standards must be considered during the design' process. The evaluation team found that these procedures are adequate for addressing these requirements.
If the above listed design considerations were not a'ddressed because of lack of knowledge on the part of_the designers and their supervisors, ro programmatic correction, except perhaps additional training, would have solved ,
the problem.- l t
Constructibility problems could have caused adverse economic effects and schedule delays, but they should not have been allowed to compromise the integrity of the safety systems.
Prudent-engineering practice would address testing requirements in the design. As a minimum, the design provided should not preclude the addition or J installation of the required testing equipment when needed or during the l
latter phases of construction when the actual plant configuration becomes l
better known. 1 Prudent engineering practice would also address operations and maintenance requirements in the design process. There is a tradeoff between the preferences of the operations and maintenance personnel, the realities The plant of design design requirements, and consideration of plant' economics.
can f avor any of these elements, but usually at the expense of the others.
' Ideally, the design of the plant properly balances all considerations. The design provided should not preclude the addition of any required items when needed, and should allow accessibility to all plant features for maintenance.
Utility personnel attend industry meetings and seminars where industry methods are discussed. Methods that work well and have general application eventually become accepted and in time become recognized as a general practice. However, the situation is always subject to change. ;
}
Practices that approach standardization throughout the industry are usually
!- those that meet applicable codes and standards, and ar'e economically advantageous. TVA must meet the requirements of industry codes and standards, but is not under a mandatory comitment to follow any other " general I
practices." For example, INP0-suggested good practices are not mandatory.
I i
i 28110-R26 (10/15/87)
c TVA EMPLOYEE CONCERNS REPORT NUMBER: ~
20400 SPECIAL PROGRAM REVISION NUMBER: 2
.Page 15 of 51 )
Although specific instances have-been identified at.all nuclear plants where certain aspects of the design process were in error, the evaluation team did-not find pervasive evidence to indicate that the design considerations stated j above had been ignored or neglected.
The issue is not valid.
4.4.2 Issue
The TVA General Construction Specifications (G-specs) are often inadequate and incomplete. (Addressed as issue "b" for all j plants, as shown in. Attachment B) !
Finding. TVA G-Specs have existed since 1939 when they applied to construction of dams and reservoirs. They have since been updated and :
expanded to be applicable to power plants. Project Construction Specifications are used to augment or modify G-Specs for a specific project or f site application. In 1974, EN DES Procedure 3.04 (Ref.107) was -issued to l govern the preparation and approval of G-Specs for the nuclear' plants. At I that time, the specs were also indexed and formal control was initiated.
The G-spec role is to provide the general guidelines for the implementation of the' physical work. The detailed "how to" information'is supplemented in the ;
engineering documents. l The recent Specification Improvement Plan Program [B05 860808 001] is in the.
process of generating more complete Engineering Requirements (ER). ;
Specifications with a controlling feature over engineering drawings. These ER :
specifications will replace the G-Specs on a transitional basis. ;
The evaluation team rev.ewed the 27 G-Specs (Ref. 126) that are applicable to i TVA nuclear power plants for adequacy and completeness. There are several instances of outdated references and in one instance, a minor conflict with >
another construction document was found; G-Srec 43 contains information on !
. pipe supports that conflicts with the SQN Construction-issued Modifications and Additions Instruction 11 (M&AI-11). !
G-Specs are not stand-alone documents. They are general specifications that are intended to be utilized alone with appropriate site-specific i specifications and documents. The evaluation team's review of an appropriate number of G-specs showed that, as general specifications, they are adequate and consister.t with industry practices, f i The issue is not valid. !
4.4.3 Issue
Engineering drawings often are inadequate in that they lack )
some technical detail (i.e., weld detail), do not always include or }
represent design requirements, or create interferences and cause )
other constructibility problems during installation.
(Addressed as
- issue "c" for all plants, as shown in Attachment B) 1 i
28110-R26 (10/15/87) l l
L _-
I TVA EMPLOVEE CONCERNS REPORT NUMBER: 20400 l SPECI AL PROGRAM REVISION NUMBER: 2 j Page 16 of 51 l 1
Finding. For WBN, the evaluation team reviewed approximately 600 l drawing-related CAQ reports 7 the EN DES CAQ Data Base (Ref.131).
Seventy-one CAQ reports (mostly NCRs) were related to the issue that documents do not always include or represent design requirements. INP0 Finding DC.5-1 (Ref. 69) noted that inconsistencies exist between the FSAR and other design !
documents. Ninety-two CAQ reports, mostly construction NCRs issued after l 1981, were due to engineering drawing deficiencies. j Four deficiencies were also cited in INP0 Watts Bar Evaluation Report (6/85),
Finding CC.4-5 (Ref. 69) regarding pipe hanger constructibility.
For SQN the evaluation team found instances where design drawings omitted several pipe hanger welds. Another instance involved the use of mixed bolted and welded beam connections. Still another instance involved the investigation of employee concern IN-85-886-N04 (Subcategory Report 22300) that no seismic analysis was performed for local instruments. These and others instances are cited in other SQN element evaluations. Also, Gilbert / Commonwealth Report 2614 (Ref. 91) found that mounting details for instrumentation were inadequate.
A review of the 12/01/86 CAQ Data Base Frequency Rep'6rt for SQN revealed that 57 out of the 3,750 CAQ documents listed (1.5 percent) indicated that drawings l were the source of the problem or the at-f ault item.
For BFN the evaluation team sampled drawings from various disciplines and the i
issue that some drawings are incomplete is valid. Out of 55 mechanical drawings sampled, 5 were found to be incomplete. Out of 35 pipe support drawings, 4 were either incomplete or had minor errors. All 9 of the electrical schematics reviewed were found to be complete. However, it should I be noted that the level of detail or completeness is relative, depending on the reviewer and the time period during which such drawings were generated.
For BLN the evaluation team reviewed approximately 400 drawing-related CAQ reports in the EN DES CAQ Data Base (Ref.131).
x Fifteen CAQs, mostly construction NCRS, relate to inadequate drawings.
i Nineteen CAQ reports were related to the issue that drawings do not always include or represent design requirements. Before 1982, only three NCRs were l written. Twenty-five CAQ reports were identified as constructibility related due to engineering drawing deficiencies. j s
The issue that engineering drawings do not always include or represent design !
requirements is valid, but Jnly to a limited extent. 'In general, the TVA 5 drawings reviewed are adeqiate.
In addressing engineering concerns and in instances where technical details
- became identified as missing or in error, the evaluation team either acknowledged in its element evaluations and subcategory report that corrective ;
2811D-R26 (10/15/87)
TVA EMPLOYEE CONCERNS REPORT NUM'ER:
B 20400 SPECIAL PROGRAM REVISION NUMBER: 2:
Page 17 of 51 processes were in place, or CATDs were. issued to start the corrective action
- process. . Specific Engineering inadequacies in this area are addressed in the-other Engineering Subcategory Reports.
4.4.4' Issue: There are conflicts between' TVA drawings and vendor j drawings. ( Addressed as issue "d" f or all' plants, as shown in Attachment.B).
. Finding. At WBN, the evaluation. team reviewed the EN DES CAQ Data Base
- (Ref.131) and the NPPs (Refs. 42 and 45); 16 CAQ reports have -identified conflicts between TVA and vendor drawings. l At:SQN, the issue of conflicts between TVA drawings and vendor drawings was.
substantiated by TVA-corrective Action report (Ref. 96), and Nuclear Safety. l Review Staff report (Ref. 63). !
At BFN, the BFNPP (Ref. 46) and the NSRS investigative report (Ref. 63b) did !
indicate that there were conflicts between TVA drawings .and vendor drawings. !
At BLN, the evaluation team reviewed the EN DES CAQ Data Base (Ref.131); 14 i CAQ reports .have identified conflicts between TVA and vendor drawings.
The issued is valid.
4.4.5 Issue
TVA design not developed well enough to be constructible; {
therefore, drawings and acceptance criteria were frequently revised f for all plants, as "1
. late in the project. (Addressed as issue "e" shown in Attachment B)
Findina: For WBN, SQN and BFN there are TVA NPPs (Refs. 43,44,45,and46),
lNPO reports, and 'NSRS ' investigative reports (Ref. 63), all attesting to _the large number (auantity) and misuse of ECNs and FCRs. It must be recognized that for these three plants the concern pertains to an after-the-f act issue.
At BFN audit reports (Refs.143 and 265) and NSRS finding (Ref. 63c) cite
' instances of calculations made after drawing issue, improper documentation of design, insufficient evaluation of design criteria changes and criteria not being reviewed by the NSSS vendor.
Revisions to drawing and acceptance criteria, when properly justified, are considered to be an acceptable industry-wide practice regardless of the state of the project at the time.
l' The issue is valid for all plants; however, it is not'a problem.
I 4 2811D-R26 (10/15/87)
x - -_
I TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM REVISION NUMBER: 2 Page'18 of 51 I
Locally mounted instruments, ITC 307 and ITC 328, were
4.4.6 Issue
installed but not specified on the design drawings. (Addressed as
. issue "f" for WBN Only, as shown in Attachment B. This issue is
< unique to WBN, and was not addressed for the other three plants.
Finding. TIC-31-307 and TIC-31-328 are air conditioning temperature indicating controllers (TICS) for the personnel access hatch located at elevation 713 feet. The TICS sense the ambient temperature and, using control 4 air, modulate their respective temperature control valves (TCVs) according to a predetermined setpoint. At WBN, most TICS are mounted directly on the
-TCVs. However, the above TICS, as well as a few others, were wall-mounted in the vicinity of their respective TCVs.
The evaluation team has reviewed WBN drawing 47W915-10, which shows the TCVs but not their respective TICS. The only engineering document that referred to i these TICS is Instrument Index 47B601-31. These TICS were installed according to WBN Engineering Requirement Specification ER-WBN-EEB-001 (Ref. 99). This specification allows Construction to determine the optimum location of the TIC according to certain guidelines and requirements. i The evaluation team found per ER spec ER-WBN-EEB-001', that locally mounted l The l instruments do not have their exact location specified by DNE. !
specification allows the installing organization to determine exact location based on certain requirements. The specific TICS addressed in this issue are shown on 47W610-series TVA drawings, along with other locally mounted instruments.
The issue is not valid.
4.5 Element 204.5, Desion Review / Verification
4.5.1 Issue
Design drawings, technical specifications, design criteria documents, and pre-op test packages do not receive a second independent technical review as required, but are reviewed primarily for non-technical, editorial details (English, spelling, etc.).
( Addressed as issue "a" for all plants, as shown in Attachment B)
Finding. The evaluation team could find no regulatory requirement or TVA commitment for Technical Review (or "second independent review") per se of design drawings, technical specifications, design criteria documents, and preoperational test packages.
Technical Reviews, defined by TVA in NEP as " design reviews," are scheduled by the branch chief / lead engineer according to the area selected for review, its nearness to completion, its influence on later designs and whether or not the area is suitable for phased review. Once a technical review is performed it need not be performed for each revision of a document.
2811D-R26 (10/15/87)
p 1 TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM REVISION NUMBER: 2 i
Page 19 of 51 The " Technical Review" (second independent technical review - called design
. review in NEP-5.2) is an evaluation of selected areas, not specific design drawings, technical specifications, design criteria, or pre-op test packages.
However, these documents may be involved in such a review.
Examples of three Technical Reviews done at WBN and BLN (Ref. 228, 229, and 230) provide evidence that such reviews, when undertaken, check more than just the non-technical editorial aspects. The reviews delve in depth into the technical content of the subject matter.
From the items cited by a concerned individual (CI) as not having been :
submitted for technical review, it appears that the CI is not making reference to Technical Reviews as defined by TVA procedures (e.g., NEP-5.2).
It is possible that when the CI referred to " technical review," it could have l meant either:
o A review of an engineering document by an engineer for appropriateness of technical content, or o A review by various design organizations of design input, design output', or other engineering documents for technical adequacy <
With regard to the first category, the evaluation team reviewed sample ,
document packages and found them to have been, by the nature of comments written, reviewed primarily for technical content and secondarily for non-technical editorial details. ;
With regard to the second category, it was observed from a review of documents that the internal TVA interf ace review system called "squadcheck" bore more i technical evaluation comments than non-technical editorial comments.
~
The Technical Reviews observed by the evaluation team revealed in-depth technical evaluations, and not mere non-technical editorial detail reviews as alleged by the CI.
The issue is not valid.
4.5.2 Issue
Technical reviews (second independent technical reviews) .
performed at Knoxville are inadequate. ( Addressed at issue "b" for all plants, as shown in Attachment B) 4 Finding. Design control measures for verification of technical adequacy employed by TVA appear in general to be adequate, based on the evaluation '
team's review of procedures and documented Technical Reviews noted above.
i However, some specific shortcomings were noted in the area of calculation l
procedures as discussed in Subcategory Report 24600.
I -
1 2811D-R26 (10/15/87)
,< 4
'):
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400' SPECIAL PROGRAM REVISION NUMBER: 2
,i Page 20 of 51
" Technical Reviews" (second independent technical reviews) are'not required' by regulation, TVA procedures, or TVA commitment. It was found that a few such reviews have been performed for TVA plants. The issue is not valid, i
4.5.3 Issue
Technical review-is not performed after the checkers have reviewed pipe support calculations. (Additional information i relative to this issue is addressed in Element Evaluation 220.12.
( Addressed ;as issue "c" for all ~ plants, as shown in Attachment B) !
Findina. -The Technical Review issue was previously evaluated for Watts Bar (WBN) in element evaluation 220.12, which stated, "The applicable requirements do not mandate any additional check or review to be made after the checker's review. Therefore, the concern is not valid." l i
Element evaluation 220.12 stated, "The applicable requirements do not mandate any additional check or review following a review by a checker." q Therefore, the concern is not valid.
Peripheral Finding. As a peripheral finding, in reviewing piping bill of material drawings for BFN element evaluation 232.8, 'the evaluation team noted
, that the same individual' initialed both the "Made" and " Checked" boxes of some of the drawings. This was noted on 11 different bill of material drawings.
These drawings include over 40 different sheets (Ref. 203), issued between j 05/68 and 02/73. In some cases, this also occurred on subsequent revisions of some drawing sheets. Allowing the individual who originated the work to check the work is contrary to accepted industry practice and to current TVA practice i and procedures. This lack of independent review increases the possibilities of error.
Therefore, the issue is not valid. i
4.5.4 Issue
Calculations are not generally reviewed by technical supervision. (Addressed as issue "d" for all plants, as shown in Attachment B)
' Finding. 10 CFR 50, Appendix B states that the verifying or checking process shall be performed by individuals or groups other than those who performed the original design, but who may be from the same organization. ANSI N45.2.11 requires that calculations shall be identifiable by subject, originator, reviewer, and date. It also states that procedures shall include requirements ,
for review and approval. The ANSI requirements do not stipulate the need for >
calculations to be reviewed by technical supervision, t.
e 2811D-R26 (10/15/87) .
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM REVISION NUMBER: 2 Page 21 of 51 Engineering Department procedures were reviewed f or establishment of calculation review and checking practices and responsibilities. TVA calculation procedures incorporate the pertinent requirements of 10 CFR 50, Appendix B and ANSI N45.2.11.
The design calculation procedure EN DES-EP 3.03 states that the section supervisor, by signing at the " submitted" block of the calculation cover sheet, attests that the calculations were performed and checked by technically qualified persons. Also the same procedure assures independence of the checker f or the work being reviewed.
OEP-10 on " Review" and NFp-3.1 on " Calculations" also identify similar requirements.
Review of calculations by technical supervision is neither a regulatory requirement nor a TVA commitment.
The issue is not valid.
4.5.5 Issue
TVA independent verification of vendor calculations and designs are either not adequate or not done at all, and design reviews of vendor deigns are not done. (Addressed as issue "e" for all plants, as shown in Attachment B)
Finding. When TVA does checking and approving of vendor calculations, the responsible EN DES design group processed them in accordance with EN DES-EP 3.03, OEP-7, NEP-3.1, and NEP-5.2 depending on the time frame in which the work was done. Independent review / design verification is accomplished according to the procedure that initiated it, such as NEP-3.1.
DNE procedures require design verifications, as defined in ANSI N45.2.11, on calculations when TVA is respons.ible for doing so, as stipulated in procurement contracts. Design reviews are one method of accomplishing this verifictti on. Design verification is not required on other vendor-supplied inf ormati on. Only interf ace reviews and review for approval are required on the o'ther vendor-supplied inf ormation.
In the transcript of NRC investigative interview (Ref. 209), the CI alleges that TVA does not adequately or independently verify vendor calculations or designs. In discussions with Mechanical Engineering Branch (MEB) personnel it was found that when submitted to TVA, vendor calculations do receive an independent review. Additionally these calculations are subjected to a squadcheck review. Evidence of these reviews was observed in calculations identified in Refs. 124, 125, 168, 153, and 225.
Per EN DES-EP 4.04 (Ref.107), the Squadcheck Process within EN DES is a systematic interorganizational and/or interorganizational routing process f or the purpose of reviewing a drawing or other design document where a response 28110-R26 (10/15/87)
l TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM REVISION NUMBER: 2 Page 22 of 51 is required. The squadcheck process is also used to transmit drawings or other documents from one EN.0ES organization to another to provide inf ormation, in which case a response is not required. OEP-10 and NEP-5.2 address the squadcheck process as interf ace reviews.
The TVA QA audits of f our contract packages (Ref s.145 through 148) were examined and they indicated some deficiencies in the vendor design control area. Tne deficiencies were resolved by corrective action taken subsequent to the audits. TVA QA audits are an essential part of ensuring vendor design c ontrol .
Review of vendor calculations by TVA is performeo only when reauired by procurement contract. A review of examples of vendor calculations determine that procedure were f ollowed.
The issue is not valid.
4.5.6 Issue
TVA does not conduct independent design reviews of its work. (Addressed as issue "f" for all plants, as shown in Attachments) 4 Finding. The definition by TVA in its Topical Report (Ref. 25) of design verification includes design review as an acceptable verification method, as well as alternate calculations and qualification testing.
It is mandatory that design verification be accomplished. Design verification is done by the responsible TVA design organization as a normal part of the design process, and to the extent identified by the procedures. The procedures allow design reviews to be employed as a design verification 1 process. l Regarding discussion on the matter of independent design reviews in the transcript of the NRC investigative interview (Ref. 209), internal TVA interface reviews would seem to satisfy the requirements of a design review, except that instead of conducting design review meetings, a review and signoff form is routed with the document under review. When initialed by review participants, the f orm accompanies the document and is retained in the Records Inf ormation Management System (RIMS). The evaluation team observed the interf ace review system at MEB in Knoxville.
A TVA policy memorandum (Ref. 235) dated 03/03/87 states that TVA is requiring independent verification for all new or revised calculations. The memorandum i indicates that this require. ment will be incorporated into the NEPs. This verification would be a secoad independent design verification.
I A procedural requirement for independent design reviews (checkers) does exist ;
and there is ample evidence than such reviews have been performed. The CI may :
be alluding to a second indepenoint design verification, discussed in Section 4.5.2 of this report. When TVA tiects to review vendor calculations, that !
would be a second independent design verification. !
The ' issue is not valid.
28110-R26 (10/15/87)
TVA EMPLOVEE CONCERNS REPORT: NUMBER: 20400 SPECIAL4 PROGRAM REVISION NUMBER: .2-Page 23 of- 51 l
4.5.7 Issue
Design checks and reviews are being performed by technicians ]
("SE". level personnel) in lieu of graduate engineers at .
i TVA/ Knoxville pipe support group. ( Addressed as issue "g" f or all plants, as shown'in Attachment B)
Finding. -10 CFR 50, Appendix B (Ref.1), in conjunction with ANSI N45.2.ll (Ref. 10), requires design checks be carr.ied out by competent individuals or groups who are experienced in the subject activity and who did not perf orm the original design. Hence, whether the checkers are technicians or graduate engineers is not the' controlling f actor.
The TVA SQN Generic Concern Task Force conducted two separate investigations relative to concern IN-85-148-001. The results of,the investigations were issued as report GPH-03-37.
The conclusion of the first investigation was:
"A graduate engineer would not be qualified to check design drawings without piping design experience and training, whether formal or on the j ob. Since only actual experience and knowledge significantly contributes to design quality, the concern to .have checkers be graduate .!
engineers is not valid."
The conclusim of the second investigation was: 1 "The concern is substantiated. However, competence in design is achieved j through educati n, training, and experience in various amounts depending 'l upon the.cmplexity of that design. While it is important to safety, ,
pipe support design in general is neither complex nor does it involve a l rapidly changing state-of-the-art. It is, to a laroe extent, standardized at TVA. Much, if not all .of this work can be perf ormed by technical )
personnel without the benefit of an engineering degree.
In addition, there is no 'TVA requirement f or design to be checked by a i
, degreed engineer. In this respect TVA practice does not conflict with )
industry standard practice." l Even though the issue may accurately identify a f actual situation, it is .
competency and experience, not the level of f ormal educational training, that qualifies or disqualifies personnel to do design checks or reviews.
._j The issue is not valid.
4.5.8 Issue
Design analysis and verification drocesses are not adequately controlled. ( Addressed as issue "h" f or all plants, as shown in Attachment B '
i i
i l l-2811D-R26 (10/15/87)
=____-
l I
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM REVISION NUMBER: 2 j Page 24 of 51 j Finding. Control of design analysis and verification analysis processes to comply with regulatory requirements is described in 10CFR50, Appendix B,
- Criterion III, " Design Control." ANSI N45.2 and ANSI N45.2.ll amplify these l requirements and they are committed to by TVA.
These controlling requirements are reiterated in TVA-specific documents such as the Preliminary Safety Analysis Report (PSAR), the Final Safety Analysis Report (FSAR), the TVA Topical Report TVA-TR75-1A, the Sequoyah Quality Assurance Manual, the Office of Engineering Design and Construction Procedures Manual, Interdivisional Quality Assurance Procedures, and the TVA Nuclear Quality Assurance Manual.
Procedures addressing the requirements contain the details for accomplishing the necessary controls (as described in the documents referenced). These procedures are found in such documents as the EN DES Procedures Manual (the Red Book EPs), the OE Procedures Manual, and the NEP Procedures Manual).
These processes address the letter of the requirements, however, some individual procedures lack sufficient detail. Some examples of this are addressed in subcategory report 24600 on calculations. There was also some evidence to indicate that not all engineering procedures were strictly f oll owed.
Therefore, the issue is valid in the area of calculation procedures.
Corrective action is addressed in subcategory report 24600.
4,5.9 Issue: Lack of engineering personnel could cause insufficient review of engineering documentation. ( Addressed as issue "1" f or BFN Only, as shown in Attachment B) ;
i Finding. TVA is aware that lack of engineering personnel could cause !
insufficient review of engineering documentation and is implementing actions to remedy the situation as noted in the BFNPP. They are also aware of the need to provide adequate resources for technical review as a result of an INPO audit finding as reflected in a TVA memo (Ref. 214) of 08/14/86 on responses to the audit. In essence, the audit finding says that the Division of Nuclear !
Engineering budget does not ensure adequate resources for technical review and l engineer training. j Section II of the Browns Ferry Nuclear Performance Plan (BFNPP) (Ref. 46) l addresses site engineering and acknowledges problems with the Engineering l Organizati on. l There is an implied lack of engineering personnel for, review of engineering d ocumentati on. The BFNPP recognizes this deficiency 'and indicates actions to alleviate this situation. The situation is to be alleviated by reorganizing engineering resources to perf orm the work where it'can be managed and accomplished more effectively.
I f
The issue is valid.
4.5.10 Issue: TVA changes vendor drawings without vendor approval.
l
( Addressed as issue "i" f or BLN Only, as shown in Attachment B) 2811D-R26 (10/15/87) u__-___- _ _ _
1 i
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM REVISION NUMBER: 2 I Page 25 of 51 .
Finding. At BLN EN DES EP 4.35 (Ref.107) requires that the Contract Engineer .
determine in consultatic9 with the design engineer and-the Division of 1 Purchasing if vendor approval is required. ]
For vendor drawing revisions 06/28/85 and subsequent, procedures OEP-09 and l NEP-4.1, although not as comprehensive as EP-4.35, also allude to coordinating j with the contractor / vendor as required. j l
A vendor drawing was " turned over" to TVA when TVA took over control of the pipe support and calculations and assumed engineering responsibility. The
" turn over" point was when ITT Grinnell had completed the final design. The contract with ITT is not closed at this point. The drawings even bef ore " turn ,
over" are coordinated for review and squadcheck at.TVA during the design cycle ]
and bef ore final design. )
1 TVA does not change ITT Grinnell pipe support drawings while they are under l Grinnell control without Grinnell's approval. After turnover (final design i approved by TVA and issued by Grinnell) to TVA, they are considered TVA drawings. As TVA drawings, any needed changes are made by TVA as procedures allow.
l The issue is not valid. ;
4.5.11 Issue: Personnel performing documentation review lack adequate training. ( Addressed as issue "j" f or BFN Only, as shown in Attachment B. This issue was unique to BFN, and was not evaluated .
f or the other three plants.) l Finding. In accordance with the BFNPP, personnel involved in the use of quality-related Nuclear Engineering procedures will be trained by Engineering Assurance (EA) as indicated by the above noted functions. The implication of the BFNPP is that they have not been trained heretofore.
The TVA Topical Report (Ref. 25) addresses the requirement for an indoctrination and training program for personnel performing quality related activities and sets forth specific program parameters.
" Indoctrination and training practices of Offices of Engineering and Construction are as f ollows:
'" Office of Engineering
" Office of Engineering personnel performing quality assurance /auality control activities are qualified through indoctrination and/or training.
The responsibility for performing quality related activities is assigned only to qualified personnel.
"The need for special indoctrination and/or cross training required to l improve or maintain proficiency may be identified by any Office of Engineering division, branch, project, or staff organization.
2811D-R26 (10/15/87)
L- -_ ---
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM REVISION NUMBER: 2 Page 26 of 51 "The Office of Engineering Personnel Staff develops the training requirements matrix which relates individual cuality assurance training requirements to specific job functions important to safety and develops proposed training program schedules, evaluation techniques, and identification of trainers and course content."
The Topical Report f or TVA Quality Assurance Program apolicable to station operations, subsection 17.2.2.3, states that the same thing as applicable during plant operations.
Engineering procedures which address training are EN DES-EP 1.16, which is superseded by MSB-EP 63.02, OEP-18, and NEP-1.2. These procedures require training of personnel in engineering procedures appropriate to the individuals area of responsibility. The procedures also require documentation of the training.
A QMS audit status log (Ref.144) dated 08/22/86 implies that BFEP training has been conducted; however, it also indicates there is a failure to document some training on Individual Training Records (ITRs). In addition, the log indicates lack of training relative to various engineering branch procedures.
As this is a corrective action tracking document, the indication.is that corrective actions have been initiated.
Training rosters for 1986 and 1987 were obtained through the BFN jobsite which show training relative to NEPs, including NEP-1.2, NEP-1.6, NEP-4.1, and NEP-5.5. Additional training records were received from TVA Knoxville which indicates engineering procedure training dating to early 1984.
Prior to 1984, lack of training records indicates a lack of training relative to engineering procedures. From 1984 to the present, there is ample evidence that training in engineering procedures is taking place.
This issue may have been valid at an earlier point in time.
4.5.12 Issue: Design engineers did not document their original procurement specificati ons. ( Addressed as issue "k" f or BFN only, as shown in Attachment B. This issue was unique to BFN, and was not evaluated f or the other three plants.)
Findino. As indicated in the BFN FSAR (Ref. 18), General Electric Company (GE) ' procured a great deal of material f or TVA in its contract with TVA f or BFN units 1, 2, and 3. In TVA's BFN 66C31-90744 procurement package (Ref.163) dated 06/17/66, f or equipment, GE procured many items using a TVA procurement specification 9065. 6-A civil procurement specification obtained f or a BFN procurement package (Ref.160) is dated 06/19/67. Electrical specifications referred to in BFN
. procurement packages (Ref.161) are dated as early as 10/25/65. Mechanical procurement specifications were included in procurement packages (Ref.169) dated as early as 06/14/68.
28110-R26 (10/15/87)
.g---------- -. .
12 + ; +
+ TVA' EMPLOYEE CONCERNS- . REPORT. NUMBER: _.. ;20400-
- SPECIAL PROGRAM ~ REVISION-NUMBER: 2.
Page 27 of 51 g x '
l 0-I
. . . . {
b Some mechanical ~ procurement.packagesL(Ref.162). identified specifics in the .!
- form of
- attachments, not in procurement specification documents.-
~l i
A~ nuclear procurement" package (Ref. :163) dated 06/17/66 includes 'a TVA procurement (specification.
Evidence exists that~ some original procurement specifications were documented. ,
1 I .The issue is not v'al'id. j
,, -4 4.6 Element ' 204.6, ECN Process J
4'. 6.1 Issue: Engineering Change Notices (ECNs) are closed out.in an 1 untimely manner, without proper status of ECN and affected design -f
. being known.; There is'a lack of adeauate tracking'of EN DES (TVA)'
l design changes (e.g., ECNs) '( Addressed as issue "a" f or all '
plants, as shown in Attachment B) ' -1
} '
Finding. A ' review of the past and present division-wide engineering i , procedures (EN DES-EPs, OEPs,-and NEPs) and site-specific procedures (Refs..
50,'53, and 57) revealed problems in tracking and closeout of ECNs.
L Requirements for. closing ECNs changed from the EN DES-EPs to the'.0EPs to the' .I
- - NEPs. Thus, ECNs were. closed at different stages of the field. implementation:
l L. m- -
. . - - of' the changes.._ TheLNPPs (Refs. 41-46). have acknowledged problems in the past =.
l3 9 ' with the. design change process and design change control.
ln j; ' The evaluation team'had found that the ECN procedures used at all of the four- ,
O TVA nuclear plants have been inadeauate in controlling design changes'in the 1
- past. , Problems- have been attributed to the lack of coordination between disciplines within the engineering division and'with the site construction
{ organization. Problems have also been attributed 'to the lack.of an adequate-
-tracking and closure procedure which has resulted in the untimely closure of. I
- ECNs. Some ECNs have been closed prematurely 'and others have remained open ,
j for11ong periods of time. !
i L .L '
L The issue is valid.
J 14.6.2' ~ Issue: Procedure OEP-ll revision eliminated space on the front cover page for identification of other documents and plant areas ,
Elimination of this " checklist," which required e affected by ECNs.
consideration and positive action by the ECN preparer and reviewer, ,
i may result in an.affected document or plant area being overlooked. 1
.j (Addressed as issue "b" for all plants, 'as'shown in Attachment B)
- Finding. The ECN cover sheets in EN DES-EPs 4.02 and 4.52 had nine questions ,
wnich required a positive response of "yes" or "no" (Example: FSAR Drawing
-r .
Modified? FSAR Test Modified?). These auestions were removed from the cover sheet in OEP-ll and expanded into a 28-point' list of considerations in
, M* J.M 4. ame---+e4%smae,.-+.www. . .
2811D-R26 (10/15/87) _
k' _. . _ _ _ . . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . - _ _
c TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER: 20400 y o REVISION NUMBER: 2
__f Page 28 of 51 f
Attachment 2 'of the OEP-R <
attachment in f or OEP-il or NEP-6.1. the currentHowever,
/ .NEP-6. l.An\ additional consideration no positive response is requird /d wa d
j:
A review of the SQN and WBN Project Manuals a NEP-3.2, has shown that project procedures a,t both plClarifications and Va responses to a multipage list of considerations Criteria. ants forrequire the Dpositive project procedure. No such positive response'is required esignin Modification thengcorresponds At BLN 8FN preparer complete, sign, an,d date the ECN checklist which iproject p>W Attachment opinion of the ev2 to NEP 6.1, and circulate the list to all revie s identical to wers. It is the positive response ~aluation team, and is typical of industry practice, that a design change are' being considered.is reouired to ensure that all possible At WBN and BLN, there is no indication'that program when it is issued. onse will be change control a positiv The statement of theLeoncerned employee that when OEP 11 -
4.02 and 4.52 the list of."yd and "no" check list of othEN DES-EPs superseded documents was'no longer on the cover sheet is trueer effected .
Attachment Attachment 2 NEP-6.1 2 to to OEP-11 require contained a positive28 and "yes" such the considerationsThe subsequent and "no" re sponse. p; Although the statement of the concerned employee is valid ;<
found that the latest procedure and its expanded list of co, the ' evaluation te decided improvement over its predecessor.
o c nsiderations is a <
4.6.3 Issue
p{/
documented phoerly.The majority ( Design Change Reauests (DCRs) '
"q are h
shown in Attachment B)] Addressed as issue "c" for all plants, as Finding. b initiated by NUC PR, that provides a request to EA design a' %
change w
to a nuclear plant. generally DCRs are not considered design documents.ngineering f or aS .!mo,difica >
agrees with the DCR, it will issue an ECN which references the DCRIf 6. Engi Q
The issue that Design Change Requests (DCRs) are not prope l gi not involved fullyin addressed only the revievby the Engineering Evaluation Team becaus of DCRs.
r y documented was M
E.
DCRs are the responsibility of the originating o organi2ati i.e., NUC PR),
6 (The F prepara and 4.6.4 are assessed in elem'nt evaluation 307.04 prepared by TVA (R f Issue: e . 101). .
The engineering modifications are not adequately scope and design activities required for identified.
"d" for all plants, as shown in Attachment B) (Addressed as issue . . .
g u
a g
.m 7
2811D-R26 (10/15/87)
- - _ - - - h
,p TVA EMPLOYEE CONCERNS
( SPECIAL PROGRAM REPORT NUMBER: 20400 t' REVISION NUMBER: 2 Page 29 of 51 t .
Finding.fJhe evaluation team focused on the improvements in i communic'ating control syptem (Ref. the.42).
change scope that are expected with thi nW, defining and {
design change 9 i The amoun[of' detail included in the brief ci ange description prov {
on the ECN cover is left to the engineering judgment rer. an q informal discussions modification group personnel. between engineers from the affected ant disttline !
i The evaluation team 'found no evidence of provision for communication e change scope between engineering disciplines in its procedure to im ;
permanent design change control system, which will be based on the PMP i j(} (
The issue is valid.
}
f' 4.6.6 _ Issue: )
long term) design changes with all discipliys and siteT const ruction.
impact of design changes.This results in an inadeouate evaluation of the
( Addressed as issue "e" for all plants, as shown in Attachment B)
Finding.
For BLN, NSRS reports (Ref. 63c), QMS audit reports (Refs
. 240 and i made for an ECN have revised for the change were somehow overlooked.
been incomplete andnges drawin '
- f. ,!
At SQN and BLN, the evaluation team found no evidence of procedures or Y.
direction for any regular coordination meetings between discipline level }(;
engineers and site modifications groups to discuss future design changes .
.h
{
In the proposed plant modifications program, all design' activity will be completed and drawings prepared prior to release of an ECN. Necessary h interdisciplint and interdeoartment coordination shou % occur e as part of t.p.th
", plant modification changes by CWstructionpackage (PMP) system prior to the installation or Modifications. of phyM hl u .
ss SQN, WBN, an(d BFN will establish the Change Control Board Ib js .
t ;y the Deputy,Sita.03redor, to review all ECNs for tfinal appr(CCB), chaired by
[ t For BLN, the evaluation team has suggested that regular publication of akgW b \ oval..
hF standard information form provided by the PMP tracking program to all @
} provide the ,needed communication of up-coming design '# '
f For all four nuclear plants TVA has acknowledged having a problem with &,s coordinating the past (Ref. 42). design changes with all disciplines and between organizations Em i
This issue is valid. 94
' :n w
r ,
1 W m 2811D-R26 (10/15/87) ,
L r
lf 1
4 y ,
' !( n ,I
'I
[ i
' TVA E'iPLOYEE CONCERNS l SPE!1AL PROGRAM
( .t' REPORT NUMBER:
REVISION NUMBER: 2 20400 1
\ Page 30 of 51
4.6.6 1ssue
delaying issue "f" construction activities and causing rework.AW exc (Addressed as f or all plants, as 'shown in Attachment B)
Finding.
tne nurfb erDiscussions (quantity with TVA construction personnel (Refs. 243) confirm that of EC8s has resulted in construction delays. The worst y ,
cause of delays was s) aid to!be " overlapping" ECNs; i.e., a
- several o?,her ECNs. unincorporated ,
ECNs outstanding against it and some of the ECNs affect
! < ,c i
./ a.$ NCRs, FCRs, DCRs, 'etc.. CCNs are preoared in response th some ide ECNs control the design work that is to be d4s not control the volume o'f ECffs issued.perf ormed and delineated on Engineering However, it is recognized that
, w % the number of FCNs and [CN' exceeds the capability of the tracking
' devipas, drryi ngs. there could be a mismatch in the actual plant configuration and plant 1
- Cantiguration This is the Control Group situation (CCG).that led to the formation of the
/ j
) The issue is valid.
A 4.6.7 _ Issue:
g ECNs that were signed off in 1978 by Engineering have not 1
been implemented as of Novamber 1985.
4 WBN only, as shown in Attachment B. ( Addressed as issue "g" f or This issue was determined to be unique to WBN, and was not evaluated for the other (3) plants.
Ofijdina: '
The evaluation team iriterprets this concern as meaning that the
[ physical work described in an ECN 'that was closed out in 1978 had not bee
' perf ormed bv Construction by 1985. >
' WEN, tic closed eben all engineering design work is completed.ECNs This has been fe plan ;>
,the
.43.02.ease .h6er the TN DES-EPs, the OEPs, the NEPs, and WBN Project Procedure
[]
,1 ;i
,/ ,
a l
, / The evtJuatiov t6n did not attempt to verify the field implementation e of th e1 3,,200 ECW issued for WBN, and shown as closed in the WBN ECN Log data L!
9 s, ./ sheets." Iscead, it focused on evaluating the improvem P!
[ i ,etticipated ire the perma:Vant design change program (PMP) proposed by [
e
' ?.INP0Goq (Ref. 220)heact:pe Guidelines .
70).
(RafiTVA it revising its desion change 2 p
E
/ In the new design change program, which is based on the PtiP, drawings and O documents revised to incorporate the approved change are held until all have been revised, and then de, issued as one package. ,
The issue-ir7 valid. '
^
\
k
'. I 14
, Q ! ..
[ t. r
\
2811D-R26 (10/15lq)
ng TVA EMPLOYEE CONCERNS REPORT NUMBER:
SPECIAL PROGRAM 20400 REVISION NUMBER: 2 Page 31 of 51 4.7 Element 204.7, Vendor Documents 4
4.7.1 1ssue
Vendor drawings received by the plants from EN DES for as-constructed "a" drawings are of poor quality.
(Addressed as issue in element evaluation 204.7 for SQN, BFN, and BLN, and "g" Issue in element evaluation 204.4 for WBN, as shown in Attachment B)
Finding.
the site are not legible and are of poor quality.The evaluation t In the past, TVA has not had a uniform vendor manual control program to process vendor manual re at the Division of Nuclear Engineering (DNE).
problem of illegible drawings by convertingSince thesome drawings Only a few vendor prints have been put onVendor the CAD syste prints will be determining restored which drawingsonare angiven as-needed priority. basis, with Operations and Enginee NQAM . Quality Notice vendor documents are legible and adequately controlled.ID-Q TVA nuclear plant sites and are still in use. Vendor documents of T/A procedures identifying vendor document control did not provide satisf actory com applicable regulatory criteria.
-1 and document control is a recognized problem at TVA, and correc are being implemented to correct the problem.
i:
O The issue is valid. L g".
4.7.2 Issue
Updates of vendor documents (e.g., manuals) are sent to Knoxville or Chattanooga Engineering, but they are not received at ,,
the plant in a reasonable time thereafter. [
(Addressed as issue "b" in element evaluation 204.7 for SQN, BFN, and BLN, and issue"h" in E element evaluation 204.4 f or WBN, as shown in Attachment B) W Finding. g e
could not beThe Office assured of Nuclear of receiving Power the latest (0NP) revisions and Office to vendor manualsof to Construc be F incorporated into their controlled copies in a timely manner. $"
received in Knoxville or Chattanooga. Vendor updates were not sent Revisions to vendor manuals were not distributed in a timely manner. TVA fully implemented. procedures to assure that existing vendor manuals are up to date "ha ...
w k
S 2811D-R26 (10/15/87) s
_ _ _ _ _ o
TVA EMPLOYEE CONCERNS REPORT NUMBER:
SPECIAL PROGRAM 20400 REVISION NUMBER: 2 Page 32 of 51 Prior to November 1986, TVA procedures and practices did not establish adeouate measures to effectively control the review, approval, and issuance of vendor manuals, vendor design drawings, and changes to these documents.
Vendor identical.documents at the jobsite and Knoxville and Chattanooga are not always A TVA memo dated August i
Nuclear Power Operations (INPO) corporate evaluation was reviewed.14,19 In this memorandum, vendor manuals,TVA e.g.: management accepts as valid the f ollowing findings regarding
" Finding (2.6A-1):
Vendor manuals retained by utility off-site organizations are not maintained in a current status. Some vendor manuals retained personnel by corporate contain outdated document control personnel and engineering inf ormation. Additionally, inf ormation in some manuals is not in agreement with that contained in the master copies of vendor manuals maintained at the plant sites."
These examples veriff that vendor manuals within TVA are inconsistent. TVA's acknowledgment of the validity of these findings and narrative regarding on-going efforts within TVA relative to vendor manual control validate the issues of this concern.
The issue is valid.
- 4.8 204.8, Communication Control
4.8.1 Issue
1 There is a lack of effective communication and interf ace control among the branches of EN DES, and between EN DES and other divisions.
SQN, issue "g(Addressed as issue "a" in element evaluation 204.8 for
[(
" in element evaluation 204.1 for WBN, and issue "f" in element evaluation 204.1 f or BFN and BLN, as shown in Attachment B) [
g Finding. a:
Criterion III of 10 CFR 50, Appendix B requires design interf ace control and coordination among participating design organizations. Section 5 b of ANSI N45.2.ll also requires interf ace control within and between organizations perf orming work affecting desio- Quality. Systematic methods
[
for communicating needed design informatic<. across design interfaces is part f of the interf ace control requirement. G To meet these interface control $
commitments, TVA has issued both upper- and lower-tier administrative instructions and procedures addressing the subject (Refs. 38, 113, 108 and y 109). " r An independent review of the Office of Engineering Design and
[
Construction (OEDC) in 1978 (Ref. 93) found that " communication among the _
multiple organizations involved in procurement [was) not controlled for maximum effectiveness." For example, there were f our organizations in contact with the vendors and six TVA groups coordinating with each other c
, I 7
28110-R26 (10/15/87)
s +
1 l
I
.TVA EMPLOYEE CONCERNS REPORT NUMBER: l20400 SPECIAL PROGRAM REVISION NUMBER: 2 Page 33 of 51 l
l on purchases.
To better coordinate purchasing objectives, the independent investigating team proposed the formation of an OEDC/ Purchasing / Division of Law steering committee. A f ollowup i investigation in 1981 (Ref. 92) found that "overall coordination between Purchasing and EN DES had improved."
In 10/81,
-were TVA's generally NSRS reported (Ref. 63c) that the interf ace controls in OEDC adeouate.
However, there were inadequacies in the interdivisional quality assurance procedures regarding interf ace i
. performing reviews, and controlling vendor manuals. responsibilities In early 1984,. the NRC SALP Board found (Ref. 205) that ". . . timely corrective action continues to be a problem when interdivisional f coordination is. required f or resolution of issues." The Board also cited TVA for " failure to establish measures to control design interfaces between participating organizations." i' 217) disclosed disparities between documented and actual o Responsibilities, authorities, and organizational interf aces identified in l l
procedures and organization charts for design and design change control were not revised in a timely manner to delineate organizational interfaces and l lines of communications. I filled in a timely manner.-Furthermore, organizational vacancies were not 1 t
Finally, in late 1985, INPO (Ref. 213c) found the following communication and coordination deficiencies: .
o
. . . many TVA reorganizations have been implemented without needed policy document revisions, with the result that effective .
- i communications and smooth coordination are not occurring." ?
o E
" Communications and teamwork between the OE and Nuclear Operations need improvement, especially at the nuclear plant sites. [ Work changes and misunderstandings) have contributed to mistrust between (
r!
the two" organizations and, in some cases, led to duplication of eff ort.
p}
Based on the above statements made by other investigators, the evaluation team p concluded that there were significant emmunication and i,nterface t coordination problems between TVA's nuclear power organizations. i m
l i.
U yf 2811D-R26 (10/15/87)
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 l SPECIAL PROGRAM REVISION NUMBER: 2 Page 34 of 51 Despite the existence of applicable procedures, there were many communication )
and interf ace problems between the engineering branches and between
< engineering and the other divisions. Responsibilities, authorities, and organizational interf aces identified in procedures and organization charts for ] '
design and design change control were not revised in a timely manner to delineate organization interf aces and lines of communications.
The issue is valid.
4.9 Element 204.9, Use of Reverse Prints l i
4.9.1 Issue
Unit 1 prints marked " opposite hand" are being used for unit 2, wnich makes work more confusing f or engineers and construction workers. ( Addressed as issue "a" in element evaluation 204.9 f or SQN, BFN, and BLN, and issue "i" in element evaluation 204'.4 f or WBN, as shown in Attachment B)
Finding. The evaluation team f ound that the use of . opposite hand drawings f or construction does make work more confusing for engineers and construction workers; however, the evaluation revealed the following:
o At WBN, interviews with TVA personnel (Refs. 240, 241, and 242) l indicate that the use of opposite hand drawings has not resulted in )
construction delays or increased costs. I
}
o At SQN, interviews with engineering, construction, craft, and j Quality Assurance personnel confirm that the use of opposite hand drawings was not cost effective and resulted in rework during l constructi on. Construction worker.s and construction engineers spent
! considerable hours using light boxes and window panes to trace drawings on the back cf the sheet to get " proper hand" configuration. Errors resulting from the use of these drawings include improper positioning of Unit 2 Reactor Vessel supports and f abrication errors on the Number 3 heater drain tank.
J o At BFN, the evaluation team was unable to find evidence, because of the early timeframe of BFN construction, that the use of opposite i hand drawings f or construction and startup caused confusion. '
o At BLN, interviews with TVA personnel indicate that the use of
- l. opposite hana drawings has resulted in construction delays and '
l t
increased c0sts.
l The use of " opposite hand" drawings has made work more confusing f or l Engineering and Construction personnel, and it has resulted in some rewerk, increased costs, ar,d schedule delays. However, experienced personnel at all l
the plants are nov f amiliar with the use of these drawings and indicate that their continued use would present no further difficulty.
Therefore, the issue is valid, but it does not represent a problem. .
28110-R26 (10/15 /8M
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM REVISION NUMBER: 2 Page 35 of 51 4.10 Summary of Subcategory Findinas i The classified findings are summarized in Table 1. Class A and B findings indicate there is no problem and that corrective action is not required.
Class C, D, and E findings require corrective actions. The corrective action 1 class, defined in the Glossary Supplement is identified in the table by the (
numeral combined with the finding class. For example, the designation D2 in i Table 1 indicates that the evaluated issue was found to be valid (finding Class D) and that a corrective action involving some type of procedure modification is required (corrective action Class 2).
Findings are summarized by classification in Table 2. Table 2 identifies one !
finding for each issue evaluated. Of the 124 findings identified by a '
classification in Table 1, 72 require no corrective action. Of the remaining issues, 51 had corrective actions initiated before the ECTG evaluation, and one resulted from a peripheral finding uncovered during the ECTG evaluation.
l
\
- 5. CORRECTIVE ACTIONS TVA's new organizational structure focuses management attention on development of adequate procedures and on training personnel in the use of the procedures. The CNPP charges EA with the responsibility f or training DNE employees in the use of quality-related Nuclear Engineering Procedures. In addition, the independent EA overview authority (audit function) will provide feedback to management on engineering perf ormance.
i In general, TVA senior management has identified the need for strengthening its Engineering organization in response to the requirements of nuclear plant design. The Engineering organization is responsible f or the content and l Quality of the design documents and for ensuring that they conf orm to sound '
engineering principles, licensing commitments, and Quality Assurance program '
requirements. This need for strengthening is based, in part, on deficiencies in design process effectiveness. This need is also partially based on past implementation of the TVA Quality Assurance program. Thus, the need f or I strengthening the Engineering organization, as indicated by the NPPs, is accomplished primarily through additional training of the DNE personnel to the.
requirements of that program and to basic management principles. DNE Nuclear !
Engineering Procedure NEP-5.2 and policy memo PM 87-35, "(DNE) - J Project / Branch Responsibilities," dated January 23,1987[ RIMS B01 870123 002), clearly delineate the responsibility,gauthority, and accountability of the Project Engineers and Branch Chiefs. The Project j Engineer is responsible f or work scope, budget, and schedule, and f or ensuring that project work is executed according to plan and in conformance with the I technical direction of the Branch Chiefs and the requirements of the corporate QA program. The Branch Chiefs are responsible f or staffing levels and qualifications of technical personnel on the projects, and for the technical ;
adequacy of the engineering design. The Branch Chiefs are the final technical !
4 2811D-R26 (10/15/871 i
TVA EMoLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM REVISION NUMBER: 2 Page 36 of 51 i
authority within DNE, and have the authority to stop work that does not I conf orm to established requirements. In the past, Branch Chiefs' authority or resources to fully administer technical reviews was limited. Under the restructured organization, the Branch Chief provides engineers and technical direction for the Project Engineer; the Branch Chief also assesses the need for technical reviews, develops a document review and approval matrix, and schedules reviews as required. These programs have been started but have not been fully implemented.
The manager of EA reports to the director of DNE on all matters other than I QA. The manager of EA has authority to stop engineering work that does not conf orm to established requirements. In reviewing EA's audits at SQN OF THE DBVP, the evaluation team finds that the methodology and performance have been effective in identifying problems and in implementing corrective actions.
Table 2 identifies 52 findings that require corrective action. Since some of the corrective actions apply to more than one plant, only 11 different corrective actions are required to remedy the 52 negative findings. The detailed corrective action descriptions are contained in Attachment B. A condensation of this information by element, with the applicable plant identified in parentheses, f ollows:
5.1 Organizational Structure - Element 204.1 Responsibility f or all nuclear activities has been consolidated within the Office of Nuclear Power; this group is responsible only for nuclear activities. TVA's nuclear headquarters and site personnel have been reorganized. Design and system engineers are being located at the sites to provide engineering support in a timely manner. (All plants) 5.2 Design Review / Verification - Element 204.5 No further corrective action is recuired f or procedures because, in general, the current DNE procedures NEP-5.2 for design review and verification were found to be adeauate on a division-wide basis. However, more emphasis and management attention must be focused on full and complete implementation of these procedures and requirements. Also, management must direct its attention
! to providing adequate staffing to allow careful review and checking of engineering work and desip documents as they evolve. The conducting of ,
design reviews is further addressed in DNE Policy Memo 87-35 (all plants). :
At BFN, the organization described in Volume 3 of TVA'I Nuclear Performance Plan, Revision 1 is in place. The perf ormance plan establishes Engineering Assurance (EA) to develoo, issue, maintain, and control nuclear engineering procedures and ensure that the procedures mesh with procedures of other organizations. EA also provides training f or DNE personnel in the use of I engineering procedures and provides feedback to management on engineering l perf ormance. (BFN) 2811n p?6 (in /15 /97)
l TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 4 SPECIAL PROGRAM REVISION NUMBER: 2 Page 37 of 51 At BFN, a problem identification report (PIR) will be written that addresses the apparent lack of design verification f or some bill of material (BM) i drawings. The sample of BM drawings identified in the CATD will be reviewed, j and the sample will be expanded as necessary to address the PIR and identify those drawings "made" and " checked" by the same individual. The design will be verified per DNE 5.1 or dispositioned by approved methods. A CAQR/PIR is to be written to identify any deficiency f ound. The PIR will be closed after all subject BM drawings are verified, revised and/or dispositioned. (BFN) 5.3 ECN Process - Element 204.6 Corrective actions under this element apply to the f our plants as f ollows: 1 o The concept of consolidated plant modification packages (PMPs) f or l controlling modification.ns at each site is addressed.in the Corporate ;
Nuclear Performance Plan. The specific details f or implementation '
of the PMPs will be in NEPs 6.3, 6.4, 6.5, 6.6, and 6.7.
Implementation of the NEPs is scheduled for December 31, 1987. t Documentation of the final disposition of the CATD will be provided l to ECTG. Actual schedule for implementation of the PMP at each plant will be provided as part of the documentation and final disposition of the CATD (all plants).
Implementation of NEP 6.3 will provide corrective action at all plants. A prescoping meeting between Division of Nuclear g Engineering (DNE) and Division of Nuclear Power (NUC PR) oersonnel ]
is required before design begins. Review of the design by all involved DNE disciplines is required during and following the design ,
process. (Allplants)
The PMP will not contain checklists. However, the PMP process will require that approximately 20 major items of concern be specifically addressed in the modification package. The preparer will not sign each item but will sign the PMP. These items will be reviewed by ,
all involved disciplines before the PMP is issued. (All plants) ;
o The CAP committed to the issuance of DNE procedures NEP-6.3, 6.4, f 6.5, 6.6, and 6.7 to reflect the design control program committed to in the Corporate and SQN Nuclear Perf ormance Plans. TVA letter
[L44 870512 802] dated 05/12/87, contains a f ormal commitment by TVA to the NRC to implement the PMP at SQN and also provides a schedule I f or doing so. The commitments are listed in the Corporate Commitment Tracking System (CCTS) as Items NC0-0870184001, NCO-0870184002, NCO-0870184003, and NCO-0870184004. Implementati on of the PMP for SQN will begin by December 31, 1987. (SQN) o At WBN, the site process and procedures f or the PMP program will be developed as part of the Design Baseline and Verification Program l (DBVP)~ and implemented before unit 1 fuel load. (WBN)
?Q11h.DOA f in /1 R /0%
1 l
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 .i SPECIAL PROGRAM REVISION NUMBER: 2 Page 38 of 51 o At BFN, the PMP process has been in place since implementation of ;
BFEP PI 86-03 on June 16, 1987. NEP 6.3 and NEP 6.4 to be' issued in ;
September 1987 and implemented by December 1987 will provide,further - ;
design change control improvement. BFEP PI 86-03 will be revised to l reference NEP 6.3 and.NEP 6.4. (BFN) ;
o ECNs issued after the operating license was issued are being reviewed as part of the DBVP. (BFN,_SQN)- -
o At BLN, the PMP program has not yet been implemented. An engineering procedure to control the work will be issued by .
November 30, 1987. Full implementation requires the issuance of DNC l and NSD procedures which will be developed after DNE procedures are !
devel oped. (BLN) 5.4 Vendor Documents - Element 204.7 There are corrective actions under this element f or f all f our- plants.
o Implement Sequoyah Engineering Procedure (SQEP) SQEP-39, " Review and
. Approval of Vendor Manuals / Revisions." (SQN) o At WBN, site-specific procedures will be developed to implement the l requirements of ID-QAP-6.2 and related Office of Nuclear Power (0NP) d policies and directives. A specific action plan identifying vendor manuals for safety systems or those affecting safety-related systems will be developed. Existing manuals will be placed under
" Conditional Use" status bef ore WBEP DNE review. These manuals will be placed in " controlled" status after WBEP review. Other manuals status with the concurrence of may be placed all affected siteinorganizations.
"Inf ormation Only"(WBN) o' At BFN, Project Instruction (PI) 87-48 is being written and will supersede DNE's portion of Standard Practice BF-2.5 which describes the drawing restoration function. Vendor drawings that are illegible afe also being restored. BFN has had a drawing restoration program in place f or 2 years. (BFN) o The corrective action is to improve the Quality (legibility) and distribution control of vendor documents. Closure of BLN Significant Condition Report (SCR) GENERI 8QO2 and completion of Corporate Ccmmitment Tracking System (CCTS) Commitment l NCO-84-0067-006 will satisf actorily resolve these findings. (BLN)-
5.5 Communication and Interf ace Control - Element 204.8
?
The Office of Nuclear Power (0NP) will develop standard procedures t'o control interfaces with support organizations (such as the Division of Purchasing).
The ONP also plans to develop five levels of integrated procedures, which, among other things, will establish management interf aces. ( All plants)
OQ11n.00A Ii n /1 C / A71
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400
~
SPECIAL PROGRAM REVISION NUMBER: 2 Page 39 of 51 5.7 Summary of Subcategory Corrective Actions These corrective actions also appear in Table 3, along with their corresponding finding / corrective action classifications. The table indicates the plant or plants to which a corrective action is applicable by the d Corrective Action Tracking Document (CATD) column where the applicable plant is identified by the CATD number.
From the Finding / Corrective Action Classification column of Table 3, it can be L seen that of the 11 corrective actions identified, one indicates a need to restructure at least part of management, two indicate a need to increase management attention to training and staffing, and the remaining eight require improvement in the quality and implementation of engineering procedures. In addition, the CATO column of Table 3 shows that, in most cases, a particular corrective action is applicable to all plants. The corrective action on element 204.5, which involves training and staffing, is the only corrective action applicable to only one plant (the employee concern was unioue to BFN).
Finally, Table 3 shows that, of the nine elements in this subcategory, f our reauire no corrective action (namely, 204.2, 204.3, 204.4, and 204.9) . The element requiring the largest number of corrective actions is 204.6, ECN Process, which has f our.
TVA has developed a series of nuclear performance plans (NPPs) to correct programmatic and management deficiencies that have contributed to the past poor direction and control of TVA's nuclear activities. Volume 1 of the NPP describes the measures that TVA has taken and currently intends to take to improve the corporate-level management of its nuclear activities and to correct the problems that have occurred in this area. Volumes 2, 3, and 4 address, respectively, SQN, BFN, and WBN. There is currently no NPP f or BLN.
The three plant-specific NPPs provide an account of the actions TVA is taking to improve its nuclear program. These measures, when completely implemented, should ' resolve the identified problem areas and prevent their recurrence.
Engineering organization and procedures, and the specific subtopics addressed in the element evaluat. ions that comprise this subcategory, are addressed in the following sections of the corporate and respective plant nuclear perf ormance plans:
Corporate, Sequoyah, Browns Ferry, Watts Bar, Element Volume 1 Volume 2 Volume 3 Volume 4 204.1 Orgar.izati onal IV and VI II.2.0 III.2.0 VI.1 Structure i
204.2 System Design VI.C.1 11.1.0 III.2.0 VI.1 Respen ibility 9
?Q11n.07A ( 10 /14 /n7)
4 TVA EMPLOYEE CONCERNS REPORT NUMBER:- 20400 SPECIAL PROGRAM REVISION NUMBER: 2 .)
Page 40 of 51 l i
Corporate, Sequ oyah, Browns Ferry, Watts Bar, Element Volume 1 Volume 2- Volume 3 Volume 4 204.3 VI.E.4 II.1 11.1 .VI.1 Design Responsibility -
Field vs Office 204.4 VI.E.4 11.2 -11.2 II.2 Design Documentation Completeness 204.5 Design Review. VI.E.4 11.1 11.1 II.2 Process 204.6- VI.C II.2 and III.&- V.7
' ECN Process and II.3- '
Scope of Engineering Required f or u Modification l 204.7 Vendor VI.E.4 II.2 II.2 and II.2 Documents III.2 204.8 Organization VI II.1 Included VI.1 q or Operating in 204.1 I Procedures -
204.9 VI.E.4 II.1 II.1 II.2 .
I Use of Reverse Prints The evaluation team f ound the corrective action plans, as stated in this report, to be acceptable to resolve the findings of the elements of this subcategory, t.
- 6. CAUSES Table 3.also identifies one or more causes for each negative finding (those requiring corrective action). For each corrective action, the most important cause is identified; however, in many instances, it was felt that the problem
'0 90110.09A ( 10 /1 E /Q7)
TVA EMPLOVEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM REVISION NUMBER: 2 Page 41 of 51 resulted from a combination of causes, each of which should be identified. In those cases, more than one cause is identified. Whenever direct evidence linked a cause to a problem requiring corrective action, such evidence was taken into account.
For the 11 corrective actions described in Table 3, f our causes have been indicated. These are shown in the table and totalled at the end. The most i frequent cause noted is " Inadequate Procedures." Next is " Procedures Not Followed," then " Lack of Management Attention," and " Fragmented j Organi zati on. " These causes reflect management's f ailure to provide a strong l quality assurance program. A strong program should have revealed at an early date that TVA procedures were inadequate in that they were sometimes l cumbersome and lengthy, and sometimes did not provide sufficient information 4 or instructions to accomplish the tasks. Consequently they were not followed l consistently. Bef ore 1984, there was also an apparent lack of training of l engineering personnel in the use of procedures. I 4
The engineering groups at the plants were separated from the central engineering group at TVA's Knoxville offices. This fragmented organization resulted in uncoordinated plant changes and central engineering group drawings that did not match plant drawings. The division-wi'de engineering procedures )
were written to be applicable to the central engineering organization and were l not always directly applicable to the plant organization. These conditions l resulted in inadequate and inappropriate procedures. The " Inadequate Procedures" also led to difficulties in the plant modification process prompting changes in procedures covering the ECN documentation process and to the initiation of the plant modification package (PMP) program. At at least one plant (BFN), there is evidence to indicate that training was inadequate because of an insufficient number of training personnel. At the same plant some documents were originated and checked by the same individual, which is a violation of procedures and prudent engineering practice.
It is significant to note that, in the early years of the nuclear industry, there was a lack of understanding of some regulatory requirements and governing documents by TVA and others. One result of this situation was insufficient documentation of the design basis for the early plants. This situation also made later verification of the adequacy of the design difficult.
- 7. COLLECTIVE SIGNIFICANCE The 36 concerns expressed in the subcategory identified 51 findings that require corrective action. All but one of the needed corrective actions were already in progress at the time of the ECTG evaluation. The corrective actions in progress or completed were initiated in response to the corporate and plant-specific NPPs. One was the result of a peripheral finding
! identified by the ECTG that required a new corrective action plan (CAP). For the 11 corrective actions identified by the ECTG, corrective action tracking documents (CATDs) have been issued to ensure documentation of completion of CAPS already in place.
28110-R26 (10/15/87)
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM REVISION NUMBER: 2 Page 42 of 51 The negative findings in this subcategory indicate that TVA's management and engineering organizational structure, as well as nuclear engineering design processes, represented a significant programmatic problem when the concerns were expressed. TVA has acknowledged these problems, and has either ,
implemented or outlined corrective actions that should resolve the problems.
However, at the time the employee concerns were raised, procedures were in place that, when followed, would have mitigated the problems. The fact that many procedures were not adequately followed is an indication of poor management attention to the practices of the responsible departments. It must be recognized that the purpose of procedures is to provide an orderly design process. The desired end product is a correct design, which is the responsibility of the engineering line management, i.e,. branch chiefs and lead engineers.
The collective significance of the findings is that, at the time the concerns were raised, TVA's management structure for the engineering, construction, and operation of its nuclear plants was fragmented. Its divided reporting structure resulted in divided responsibility and poor interdepartmental c ommunic ati on. This disorganization was especially apparent in the control of engineering design changes and of design change documentation. If organizational and procedural changes had not been made, eventually there would have been a significant mismatch between the plant configuration and the enoineer.ing drawings and records, which could have resulted in an engineering design error or plant operating error. The present-day organizational structure and operating procedures, when properly implemented, should mitigate problems such as those experienced in the past. l
{
Of particular significance is the f act that the need for strengthening the TVA I Engineering organization in response to the requirements of nuclear plant design has been identified. The Engineering organization is responsible for the content and quality of the design documents and for ensuring that they conform to sound engineering principles, licensing commitments, and Quality Assurance program requirements. This need f or strengthening is based on past deficiencies in design process effectiveness and on poor past performance in
. implementation of the TVA Quality Assurance program. Thus, the need for strengthening the Engineering organization, as indicated by the NPPs, is accomplished primarily through additional training of the DNE personnel to the requirements of that program and to basic management principles. DNE Nuclear Engineering Procedure NEP-5.2 and policy memo PM 87-35 clearly delineate the I responsibility, authority, and accountability of the Project Engineers and Branch Chiefs. The Project Engineer is responsible for work scope, budget, and schedule, and f or ensuring that project work is executed according to plan and in conformance with the technical direction of the Branch Chiefs and the requirements of the corporate QA program. The Branch' Chiefs are responsible for staffing levels and qualifications of technical personnel on the projects, '
and for the technical adequacy of the engineering design. The Branch Chiefs are the final technical authority within DNE and have the authority to stop work that does not conform to established requirements.
2811D-R26 (10/15/87)
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 REVISION NUMBER: 2 SPECIAL PROGRAM Page 43 of 51 An independent audit on the effectiveness of the implementation of the total Quality Assurance program is instituted by Engineering management, as a management tool, to additionally ensure that management policy is being enforced. This audit function is provided by the Engineering Assurance (EA) organization, which provides feedback to management on engineering perf ormance.
The results of this subcategory evaluation are being combined with the other subcategory reports and reassessed in the Engineering category evaluation.
l l
t, t
28110-R26 (10/15/87)
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400
- f. SPECIAL PROGRAM REVISION NUMBER: 2 L
Page 44 of 51 TABLE 1 CLASSIFICATION OF FINDINGS AND CORRECTIVE ACTIONS Finding / Corrective Issue / Action Class *
.. Element Finding ** SON W8N BFN BLN C7 C7 C7 C7 204.1 Organization Structure a A A A A Requires Excessive L b Document ati on, . Reviews / c C2 C2 C2 C2 l A B Approvals, Procedures, d B and Response Times; e A A A Design Responsibility; f f or WBN C2 (3) (3) l Communication and Inter- f f or SQN, (4) - C2 C2 f ace Control BFN, BLN g WBN only - C2 - -
h WBN only - C7 - -
]
204.2 System Design Responsibility a B (1) (1) (1) b 'A (1) (1) (1)
A (1) A A 204.3 Design Responsibility a a C7 C7 C7 8 204.4 Design Document Completion A b A A A c C7 C7 C7 8 d C7 C7 C7 8 e C6 C7 C6 8 1 f WBN only - C6 - -
i (6) B (6) (6) a A A A A 204.5 Design Review Process / A A A Independent Verification, b A A
c A A E6 Policy and Practice Vendor
- Explanation of classes is on the next page.
- Defined for each plant in Attachment B.
, (1) Issue addressed in element evaluation 204.1.
l (2) Issue addressed in element evaluation 204.2.
(3) Issue addressed in element evaluation 204.3.
(4) Issue addressed in element evaluation 204.8.
(5) Issue addressed in element evaluation 204.7.
(6) Issue addressed in element evaluation 204.9.
l 28110-R26 (10/15/87)
DTVA EMPLOYEE CONCERNS REPORT NUMBER:' '20400'
?- J - i.
REVISION NUMBER: .2 b+f
. 'hi M (*St?'"
-SPECIAL PROGRAM.
Page.45 of 51 7
.. ) i TABLE 1 (Cont'd)
Finding / Corrective Issue /- --Action Class
- Finding **- SQN WBN BFN BLN' 1 Element 204;5 DesignsL and Calculations, . d' A1 A: A A e A A A- A (cnt'd) Changes to. Vendor Designs A l f- A A A g A A 14 A h A- A A A 11 f or BFN - - C7 -
i f or BLN - - - A j BFN only; - - C4' -
-k BFN only: - . - B- -
a1 C2 C2 C2 C2 204.6~ ECN Process C2 .A b A A c A' -A A A.
d C2 C2~ C2- C2 e C2 C2 .C2 'C2 ;
f A- 'A A A' g f or BFN - - B g f or WBN - C2 -
- a. -C2 7 C2- C2
~ 204.7 Vendor Documents C2 b C2 7 C2 204.8 Communication and Inter-- a C2 (1) (1) _(1)
'f ace Control B (7) B B 204.9 Use of Reverse Prints a (1) Issue addressed in element evaluation 204.1.
(7) Issue addressed in element evaluation 204.4.
- Classification of Findinas and Corrective Actions A. Issue not valid. 1. Hardware No corrective action required. 2. Procedure B. Issue valid but consequences acceptable. 3. Documentation No corrective action required. 4. Training
_ C. Issue valid. Corrective action 5. Analysis initiated bef ore ECTG evaluation. 6. Evaluation D. Issue valid. - Corrective action 7. Other taken as a result of ECTG evaluation.
Peripheral issue uncovered during ECTG -
E. -evaluation. Corrective action required.
- Defined f or each plant in Attachment B.
x 28110-R26 (10/15/87)
-)
n, TVA EMPLOYEE CONCERNS LREPORT. NUMBER: 20400
- SPECIAL' PROGRAM .
' REVISION NUMBER:- 2 ,.
g._
..Page 46 of.51. d l
TABLE 2 -l o
' FINDINGS
SUMMARY
~ Plant ,
.j Classification of Findings SON WBN BFN BLN. : Tot al Issue not.: valid. No corrective 15: 15. 13- 16~ 59; A. .)
action required.-
B. Issue valid but consequences acceptable. 2. - - 4' 6~ 13 No corrective ' action required.
C. Issue. valid. Corrective action - ' 12 16 15- 8. 51
. initiated before ECTG evaluation..
LD., Issue valid. Corrective' action taken - - - .- 0 as a. result of ECTG' evaluation.
. E .' Peripheral issue' 'uncovere'd during - .
1 -- 1 ECTG evaluation. Corrective' action required. ,
i Total 29 32 33' 30 124 l
t-4 l
l L.
l' L-t e
-em_ nWZ '.* C - ~ ~.
A 28110-R26 (10/15/87) .
U--- - - _ _ . - . . _ _ _ . _ _ -
1 lllllllllIl[lllIilllIllilIlliIlI1t!III!III e - - -
v H - - _
2 llIlIll!I1IliII
- i- fot es
- i IlllllIl1llIl1ilil R f c n - - - -
E t e e o M -
a B 3 g n r t c rt i 1lllllIIIl1IllIlIlliIlIllIIII!lII PS CF i a o c s cC A 0 4 A A A A 4
0 7 0 lllll[li1 rilllllIIIl11llIIiIliIl1llIIlIIiI' 1 4 c r 5 7 d o l E 1 n r e r VG E A RP L 8 lll{( Illlll V E III1l1ilIIi1lIIl1ll!IlIIl1I .
AY g r C C 6 r ro I
N UA 1 g n r HQ E E C E T A ls llll(
E D 5 - e d I[llllII1lliIlIIillI1llll1IIIli1I -
1 d t l w -
t o o o 5 nF l IlI lj l 1 lllf Illl ll1i1llIlll1l1l!1lIIllI1Il e f - a 4 ui ut n 4 s r c n o -
n e oet i V D mt ll[lI Illlllllll11jlifi1lil l
,lllI111IlI 1
n g/i t
t S
3 8
i t si e r oN M mto e _
IlI S DCC Illlll1Illl1llIII1lIlllll1IlIl E 1 ll]l! -
N t d E g - e V 2 r gt ut -
I 1 gd oc n -
T n u n Do me C
E i t J
{llll Illlll lIlllllliIl1lIlIlliiIlllIlI f nl t gi f a E l icf
- I a e ist S L ee D 0 I11ll1IIlllllI S S IllllllIlllll1i1ill E llll1 G i
- t -
N C I O eei n _
D R o d t b o .
a a - cl N P t I n u s et F
G N
I I qA R c l[l[1 Ill[lllIlllllli1illIl1lllIIl11ilI -
E 1 V 5 e e s l E 9 d t c S l C a al E A n u a S G I qC Illl ll1IllllllIlIll IllIllI I lll1lI lllll U t 1 A
C a ee g sn F 8 d t i e D O a a s s N n u e aB -
A S
E S
lll llll I qD t
( 1ll[lllIllllll1li1l1!ltlllIlllllI -
S u g n R A 7 k M e x 0 C c t 1 af t 1
C 6 lllloAl L 1ll]llI1tll glliIil11IlllllIllIllI yf s A0 l o eu 0 e E4 6 V 0 - es s I 2 nt e s -
T U t R l lll[lllll[ s1l .iIilllililll1ll1llI CT 5 l Illll 3E R 5 - n RO E ee - o -
ER G N 5 d t t i L OE E a annt B CT V n uou a i qC sc P,lilIll11lllllI A A l i 1 llllI lll[llIIll8 ll 1IIi7 T .C -
SB C T U E es - e d
1 NS F 4 c e 1 E F o rt l w E
M E Prd uo N F e lo ll((llII1ll1ll1!illlll1lllll llllI L T 1lj[ll C N - -
E ee es X F M 3 d t c e aa 2 x n uor 0 E I C I qP a r u lllllI I A llllllIIllllll1lllllll1llll
! N 1lllll .
R A -
T M ee d t - e A 2 _
M a aQn n u r 1 lj[lI t q t llllllIIlll 1lllIilllllllllIlllliI d -
- en gt a - n I
a n ga o X x r e r rt lII illl[llIl f mOf t lllllllI1llllllIilllllllll1lll l
i 1 1 2 1 1 n 1 2 0 00 00o 0)))) t 0)))) N mN a M N u D M N M P 1 S QsF t uanN 4 M7 Ml t 7 f Qt T
A 1 SB F P W B Lv B P S wB a 4 R(t(t QerL 5veB S
4 W4 S B Ql 4 B S e -
C 4 N(((( 0 0 0 0 0 2 2 2 2 2
y e s . h ly t e
nd n us e s s e i l r i t m o N
Eh e isv ric o e t i, r l ni a u f at n f u b et oq . e _
O C r S e a oe nsdee oa m n t t uun t t b n
TI C
ed gP t nnP ct te l r r
s o r c uo s c o s o r e d A a aiN l c nu anp e a g s ee ea r e mh d ep r s eof i e
rd d os i e r pos .
m e
e t
e t
v l e o sl e l eoh t rt f r e-oo t Si p t l outlaog v
c r n u n r ev d a o u e e d s u
df n e oi g l p
p u
l p
m r~.
i c .t t s pi cs ns c w o _
r oe S r u ar C a y$ n r r o u eil o e c e d c re a n c E
A f t rit cp ie m 'rc an se t
urE e o uoe rt v pa s u o p s d s
y r n R el a t h e f d t f s nt a o _
D t i s s ,d t soea t t i r C nb s re r e c Ot lr n u , r o s n deoc o inn ef g n yt d r mu b n
e sd o s s
e i
t .
cd i is e u a en ed f a rt gt s ei c a pr me e
- e. f ed ri el r ao r ms e en e l E
1 e
a eu n o n e r = u e i rt d t l r v es r ewar ai l l i pi c e p a nd n s pd v s )
f s g ot n s a pS eE ioit ml o n ei md f e h
b a ii 7 e e n r n D r epi oohc.o F P p R ovs i ccavd I a o t T t ct 8
/
a n e r 15 E
- l i ro r p / -
/ T *. d d oe 0 Gl N e e c r 1
(
N Y O5 n n CI S Dt IDE k R C L TA i f
i f
e f n A e 2 R A C 2 e i 2 2 D D C m 1 FI O C 2
C C C C C ol e R 7
- ne 0 6
1 8 *
- i. ) 9 M 4 4 4 4 1 7 E 0 ( 2 L 00 0 2 E 22 2 Il\
l i
l
.a _ mes - e.m _ n== een e.a e m e_e.o e_ -= == e_ _m e- =_ .m. -- === e.=e e- ---m e_ ===
e ene -m e- ._ -as .ee m em e-. e use I f N e 3 e e. e e e == e 4 O ed om umse amo amm e_ men m aan ene amm vem a_ eum smoose - e_eems aus e- a_ ene e_ m num e_ e_ eums ene - ens eum amm mee e-it.
ee as*
sg - % vC am 6 e f 4 a= et es o I t c v b 6*ed a_ e=* **** *** ** men * ==* *=passa masm one ene ese asas aus === ese aume em mee amm anus enn ==s ames es-
==g gye C e- =ue e.us ==* == e* ese aum* **u*
e= 4 0 w & C 4 W 4
,g O 80
.e=_ _.e.m_a_.e_a M wwe O
_ e.
E
-e.m_e- m-m__.__ eeme.m e__.s==_..em.me -mm __a _ . _ -
me er b O O e_at h_ g $
a.m- ;
in, e_ eme.m -e ame_m_e g" ,* , e a o.o m .s.=a _._m_e.__-
- e. e.m. _mm e.m e - _ 1 i
> 88 b tJ ma et to
- gB ". IOt w tee ens aus unem eumamm one mee== emo een main me esoone apse emmene menee eumuma som amm e_ amas amo amme one ess aemme amm -m aus ==
n.a mm ens un- ame one mm.
>=
9 in et t O
= W W *
en O e a=
9 en 5 w ens au ese uma ese aus ese == ese amas em emme em eien amm amen m een enum em em mee == une emme em e_ m eum ase eum aman e_ een amm amm amm eum amm em e
it.e wee s == 3 ** 5 O
_e en 6
==
o E er
> en _m une emse amo eump aus een m ene enum es e s e emum memih amma en.pm em esmo one aman a.no esse eum e_ esse ene amuseum amma s ing.us aus- -l ens _esesos esse eme eau m == es
&%- ed es ea, O a- me e- O e e w b E E
- m amm m.
@ O Y U mee me ese e mn eme m one uusi e e
== -e m.m e-- amm -. == eso. -as one amme enes summenn amm a-m aan == e-a-a ene e.m._ ._ ese m
F b ea
. 2a O .
]
5==
- 48h O W
e
> a 2 C u saJ _o a m g == === == m s =ie m.m -m e m em e m ene em.m m. e es. em. a=. em. aus --e e_ - .m. e. m ese - em m -
w . a'"5
.e em e
.w C **
w in, M
w w 98 - ** e O e ===
= e 0 e e, m e_ ._5e_ _5 e_ _ e_ _me_e Y,,,_. _.ememme_._ e_ _ em.e_ _e e_a u e e_ _ e__-a.m _ =_ s g U 6 ed a d
meO O
eg E
O
- v* e 3 *e* &-6 OV ** e O as f ame C S se @ == e_ a_ em m M me a er es v amo mas ese emme e_ aume emms - eum amm eum -esse esso new ggy amm. ese -me emman ese eum eum amm use ese sum one amme eum ese emeense amm amme ene m ese W
es G
w en 4.e ve ** u O M m- O e a-at a s e emme esas em s.= Fv (9
o - ese one mee ee s men eum amm ammamm m ese eum one suas eum aus eumasum sans esemen en- em aus aus ese e=== === ese mean numa emme enn aus eau E e c ee ce en O s.m. e 9 * * = = w e as ** e O e a es e me FQ - esse ===
eA mes === ==s ===emm === m- ame one eme e enn een ene amm - aum ame === e_ ese amme== === ===
am. _ amo em === e eo-.u-eme == een mas e
. N *e ce g e N 3r Pe Mv E ei,s M M O e sem es e.e une mas ===
esa enn asum e.J. =e et. amo ans one ese me auss une ene amm amas eum --n amo amme amm oneese - amm eum es- amm === m aman -en ese an==sms _m ens m, *e==
w 8 te
es 0 ers O E I h e4 C == to en e
me num emum aus D me aan e-a-. ===- asms mesa een meneenemme one amme one m een m amm em aum em amas oss een em man- enum es- ema muse ens m.us ans De M ens emme u.se.es Mw M e c y ## e 6 0 i w e6 en U es en == O M 4 e **
l e- E a o a es= ==s e-I i to et =.=.e- _===.==e__ae p
FV W ==p.=m==e-====a,====-==e==mnea==_m========_mee-memme-.===
e u e W
> w el e4 M E w er V e **e 4 ea M w O b nad b 3 O e 6 mee esse een men amm _un ame - m ame ==. ese ene -me -
em M E w *=
ese===e_a===- sum eso essa emme amm en ease ens e_ essa muse ammamm een esse ene amms ese amme eJ De == l naJ w1 w G 9ee i w Y m = e M M M M e j O e e u s ena e e. g b ene === ame amo eue ==
M en === mee === ene en amm a === == ene === == == ese mes == === ese amo one guma mamm amo an amo == e.- ene .mo eum use ese me 2 "
- a. O 5 1%bi ee b mee F e.a amm ammeone ese aus eum eum aums ammanasum eum amm som eum aman m-
_ eum -en een esse suaseem e ammt enum aum mum emme esse amm een amo eum enn amme an.m en- enn
.e 4.
E.
. $ e. 8 N j b
i.e 5 e4 =,= am.oeens m weama suo amm amm emum -eum m emme- man- e_ eneaume esas em eum ame a.no ene e emme e amm l
ememme ens ease esen emme e-m ese -
=* N NN ==e N M N O O OOOO ami === O O O O ===E = =E E E
w E E EE EE E R$kd Mgk - - g =JS k k ;
O k 2 -
e l
}
es O
e=
e G Et E
& S 4 u ef es me O b w 6 b en go g O m he ed g 6
- f. 3 en q p en e& a me e e e t == c ==
==u
- O a= ** &
e om et b W G W W T e W W ten E ** c i
ea 9 eC O C gh as as == e C e e e
- J ef s 4 g W b & **
c On a(
d gne ao se e e e" E w 9
a O eh T b
- en C ==
a *=
es en- W L c WE b ea &
== es 3 U es ==e O e8 E 4 > W ea ** D i e g am gng g es W In 9 C es M tad D* es se g 88 e e sah
== en et et a= 0 9 E et b
W et es es
, et ** b Wh == C &K et ed O 54 b C i
& E s." T O em W e O 8 hs ** ==
e b 3 en e8 te na **'
5 C
e
& e8 se ewet E
sa&
en e4 e
- =
ed e W@ e g =*= 0 0 8'* WW e@
D
- "C" S W G e
ei es g
v> af
==
v om en W
e g3 e 3 D E A e=On a= as p et to C@ W@ W > an O O e*WI W *= SU e e T
& b & ,C b A
A e en a=
e, b ee
- e. dweC . atW G b se == & 3 h W ma Eh e4 he e8 osemm W ef %
l C E W in a=
I had e == == b b '==
e 0 ed O
- t.2 E
===>W
== e 9 e
9 e ed b ==
meW>*me O to e C a=
E es- O ea
==s*
Q ned om e w w m-E at U _t.a N me eC Q N N e y aql m N =0 N W O Q W bD taf W N.)
4 b> "etq p same e e a w Q w
s en te* 4 s ain (Ps R
- se pmm has l see mim* 8%Q I
hlO
) **
\
\
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM REVISION NUMBER: 2 Page 49 of 51 GLOSSARY SUPPLEMENT FOR THE ENGINEERING CATEGORY Causes of Negative Findings - the causes f or findings that require corrective action are categorized as f ollows:
- 1. Fraamented organization - Lines of authority, responsibility, and accountability were not clearly defined.
- 2. Inadeauate cuality (Q) training - Personnel were not fully trained in the procedures established f or design process control and in the maintenance of design documents, including audits.
- 3. Inadeauate procedures - Design and modification control methods and procedures were deficient in establishing requirements and did not ensure an effective design control program in some areas.
- 4. Procedures not f ollowed - Existing procedures controlling the design process were not fully adhered to.
- 5. Inadeouate communications - Communication, coordination, and cooperation were not fully effective in supplying needed information within plants, between plants and organintions (e.g., Engineering, i Construction, Licensing, and Operations). and between interorganizational disciplines and departments.
- 6. Untimely resolution of issues - Problems were not resolved in a timely manner, and their resolution was not aggressively pursued.
- 7. Lack of management attention - There was a lack of management attention in ensuring that programs required f or an effective design process were established and implemented.
- 8. Inadeouate design bases - Design bases were lacking, vague, or incomplete f or design execution and verification and for design change evaluation.
- 9. Inadeauate calculations - Design calculations were incomplete, used incorrect input or assumptions, or otherwise failed to fully demonstrate compliance with design requirements or support design output documents.
- 10. Inadeauate as-built reconciliation - Reconciliation of design and licensing documents with plant as-built condition was lacking or incomplete.
28110-R26 (10/15/87)
J
m ._ .- -- - - _ _ _ . _ _ ,-
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL' PROGRAM REVISION NUMBER: 2 Page'50-of 51 l
- 11. - Lack of design detail - Detail in . design output. documents was I insufficient to ensure compliance with design requirements.
- 12. Failure to document engineering judgments - Documentation justifying i engineering judgments used in the design process was lacking or l inc anplete. l
)
- 13. Desion criteria / commitments not met - Design criteria or. licensing 1 commitments were not met.
- 14. Insufficient verification documentation - Documentation'(Q) was
'i~ insufficient to audit the adequacy of design and installation.
- 15. Standards not followed - Code or industry standards and practices were not complied with.
- 16. Engineering error - There were errors or oversights in the assumptions, methodology, or judgments used in the design process.
- 17. Vendor error - Vendor design or supplied items were deficient f or l
the intended purpose.
Classification of Corrective Actions - corrective actions are classified as belonging to one or more of the f ollowing groups:
l '. Hardware - physical plant changes
- 2. Procedure - changed or generated a procedure
- 3. - Documentation - affected QA records
- 4. Training - required personnel education -
- 5. Analysis - required design calculations, etc., to resolve
- 6. Evaluation - initial corrective action plan indicated a need to evaluate the issue before a definitive plan could be established.
Theref ore, all hardware, procedure, etc., changes are not yet known
'7. Other - items not listed above Peripheral Finding (Issue) - A negative finding that does not result directly
.f rom an employee concern but that was uncovered during the process of <
evaluating an employee concern. By definition, peripheral findings (issues) reauire corrective action.
t .
28110-R26 (10/15/87)
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM REVISION NUMBER: 2 Page 51 of 51 Significance of Corrective Actions - The evaluation team's judgment as to the
, significance of the corrective actions-listed in Table 3 is indicated in the last three columns of the table. Significance is rated in accordance with the type or types of changes that may be expected to result from the corrective acti on. Changes _ are categorized as:
o Documentation change (D) - This is a change to any design input or output document (e.g., drawing,' specification, calculation, or procedure) that does not result in a significant reduction in design margin.
o Change in design margin (M) - This is a change in design interpretation (minimum requirement vs actual capability) that results in a significant (outside normal ' limits of expected l
accuracy) change in the design margin. All designs include margins to allow for error and unforeseeable events. Changes in design ;
margins are a normal and acceptable part of the design and !
construction process as long as the final design margins satisfy regulatory requirements and applicable codes and standards.
o Change of hardware (H) - This is a physical change to an existing plant structure or component that results from a change in the design basis, or that is required to correct an initially inadequate j design or design error, j
If the change resulting from the corrective action is judged to be significant, either an "A" for actual or "P" f or potential is entered into the appropriate column of Table 3. Actual is distinguished from potential because corrective actions are not complete and, consequently, the scope of required changes may not be known. Corrective actions are judged to be significant if the resultant changes affect the overall quality, perf ormance, or margin of a safety-related structure, system, or component.
I t,
i 1
4 28110-R26 (10/15/87) l 1
r_ _ _ _ _ _ _-
.i 1
- TVA EMPLOYEE CONCERNS REPORT NUMBER:. 20400 SPECIAL' PROGRAM. . REVISION' NUMBER: 2 Page A-1 of.8.
. ATTACHMENT A-EMPLOYEE CONCERNS FOR. SUBCATEGORY 20400 j
.! Attachment.A -- lists, by element, each employee concern evaluated in the )
' subcategory. - The concern's. number is given-along with notati on of any other subcategory with which the concern is shared and the~ plant sites to which it could be applicable. .The concern is quoted as received by TVA and.
characterized by TVA' as- safety related (SR), safety significant (SS), or not _
safety'related(NO).
j e
4
.e f
J 0107A-R50 (10/15/87)
M is s UF N0 h h n 's y eb ea lyna ih e raa yose) a y fO t
s T .t sd n inn t r h yl m efN id n N2 sn' na i noet el eh a( o sip a g et noh aunt eC O -
A . e Ehe nn rionT coo n 's h IS ece d ei rnea Yhf e poe". t t I E m ol orp . nv yi rs uom, cmo .o u
bn f
asn VG s posao Sscy .ee r reo EA ot RP r enpr eemr p fl u ise n nt oent tbac yhl se coi dt b g uo t s o .i oi ahn e a miyd ot se yedt ,sl ne o h gm usnet o er t merl riogyc t inr o ceac n u ) i ot oaeb dt q0O i s en p c pi orf stll sei .
d moh l t t en d r gd e9N n e o p ul ah o ou r
m
( ibt ogat mlnogoueirenewa p pn ei N t tP ro oe snaccop n qD uir g E h c n ri e snk ge IO inn; t tt".
) ym s osf nl oeo ,R snh T ik y d pi aenrsthE net P d rnsn tSe s sh rocW o r I l noaea e t eeicesl enaO i nu R yrs rr ehi ap oP isef C iieowms r sl oy eymt c sr h S wseoaa nupopr ef s n
nht eiti pC pU ct o e n E
D uf at e osd igTil herr eehhna nan dd np kn nt e s hh ct o ns N so icf sog
- re dia nt d
e .it niso b tT e t sre .
sd l aa a h R
E oow nol osen aet s cr C eo rtt eei mrs ape r
msnl a erod
.r mon pnl ei i el n gC N
O u n mp .t t epn , ef oema h n C td u ,an sey s psa nt oh gt ca cao pr ost y eh osnst ae eh .
uems ece m e scr i yo rd t g rl gf rt s stf en) t a 'R h n 2 na (i s l f i eea ihh t en d aa hsa l yhiR nt wS sseCT o eve' c ) era d lact re t nh ettih on oet pu a
mnr a(
l mi 0 iais , sR sa n gn ep vs .aued nm eb yti t oi gd 0 ree t ss .iS dh( oeo o n rl ,lkfi o s d ".
4 0 e m c 'N goxC n et pr s k ag ,tddecod it sn nmi d t een dt r 2 enr ic oscnaaaut a s ce Y
aseEit".
n l a roo ft eaI h e
nql uo et uc vf rn R an rmhs i w i d r t srl sysn aat o Mo: ott cd O ic ft oam re ersc G
E stl i ef e apet ei rdf k ro mr eel nl pnl oohi sgacrt vov e l 'n e r sa l cno .
T A 'A Vt ac uml st c ae cof af r i r oseengort t exs ah A V g-
.ct p
C L ne N svh ooneusI T . se A B Ti x yet p
" ip " aot ctKpoAC " eaD U " sE cbss T S M 1 fF R t O e4 C
i F N e0 A S L X XS2 X I
N B T
A R E 1 C
N e4 O Y N e0 C Tf X XS2 X E I B E L I
Y 1 O B 1 L A e4 e4 P C e0 M I N e0 LB X X XS2 XS2 E PW P
A l2 d X X X j
N O N I N N N TT B B B B NA W W W W AC LO PL
)
0 0
0 2
2 2 1 0 5 0 0 1 1 h Y 0 0 0 0ti 9 7 9 1 w 2 4 0 9 N 0 0 2 0d RR - - - - e EE 5 5 6 5 r CB 8 8 8 8 a NM - - - - h OU N I 1
is
. CN I W 1 W(
T N 3 E 1 2 M 4 E 4 4 L 0 0 0 E 2 2 2
M d na eet ss U rl ea r w( h cies t o e n N eac prrk t
c lbti l a di h
r u
h t .
ger t e N oeocr i it efi yT f in d ec O nf ao f". crnrn wr lelpo n se ro i l ueoea t e I
S r gt t p cl rh ct M . o sc l a o mc I e o ea t w i d en gn pt s f r eg no ccs V
E iddnod sae n t n a
se nsoc . gl s oa nnua ic w
( nu i o R .d an s n
osae rm ceangavn r e gi h i ro nny m
ct tO e. al eariscdl ase C di t
oen i t o nesP i n b d eryN o n ed gd ec t f n nmesI ,i oi n d nl l u a oA st riu . b r aeh rTl o li t
d i
geeon at) ic e
- si at i d h e y n gb wr k sO f r .
N eu m ad gtli n e rnN an O s q .rd t a uul ral nc oo( ic o I sesoe e ot aehl on wC e)i prt T ersfi d o niie ii o g sea P
I r
d ncoi) d oontR e f e
t s n et cnctt c s e ii s a l npgm m.
n ins
.". nmr b m R ea t ol lisns ert C
S air t p ,e(
nS l h e wg eeirop aii iouo nf E yc sd p eaf e et a t n D ml ns)s nD rat a le unei r gi s". oE di e2 ai cl e l N
R t ti t assimn c eeg pb n ri orro n
h a l d l a - e U E unel eo w . o a .f eei t t r tGh C qodili on lell hc gswlyirrut c t ht iwn so s nar t
N ec t bt h r O
C d
adh euoa rm se c
vi e: tl drcur s I o n dt i hf u Innt rpr sn yo d sa a ft s
mni a e o mrl e leita nio nh rf ac t eioucyn a wn
) gi t on w or nd cnno b sm S n ofi l n nainiaAC) omr t ,s Eis ao mett R reo ssa Dt eht e i es vrp S pl f ech 0 N sct nc tt ren ae . .( b n t e 0 E eiien oc egedpcny soi a r pl 4 (tt wme nur wnen ,crt n pl n
,sC)
R c ti aba aei".
0 g ,asir ot sh t cl a on S 2 nernn e d s nceAnrnan t yn i o .(
Y cpon p u n g vV eooio nno ti e R irn i ox so i naT t cti eai ctt O
G e a yt ce enrc net anC i gC n
s gh ei d sd exrid m sa niicea nt mmt e
ggd i ruca t rqr u u ".
E it s r gR w . el eeerir and st ee T
A gnueiN ae Ad uw - t ef o nia nsdt C nidt s rz V ot ninnf av onat A B E annsf Di T)h eoreon Mao C one U " mI i ao " s " 1 sbncgci " nn " cil T S N
E R M O H F C N A S L X X X X X T N B T R A E C
N O YN C TF X X X X X E I B E L I
Y O B L A P C M I N LB X X X X X E PW P
A MX X X X X N
0 l N N N N N Tl B B B B B NA W W W W W AC LO PL
) )
0 0 0 0 0 0 5 2 5 4 2 4 2 2 2 4 4 4 ?
7 3h 0h 10h 0 0
l O
0t) 0t i 0t i
- i0 - -
0 w0 1 w 6 w 3 0 0 7 6 8 3 0 N 0d 8d 1 d0 1 1 RR - e3 - e - e - -
EE 5 r 5 r 5 r 6 5 CB 8ad 8 a 8a 8 8 NM - h n - h - h - -
OU sa X s N s N i
- CN lW( E( I( I W f
N E 4 M
E 4 L 0 E 2 ilr l
R lp E
e wau n o
.s a
git l C r v ueoi esvf t p B8 d t a M d yqe t ie. h l
b cm ur ora d oi l
eh a i a UF ul er ' p led N0 nd a e l ro .) nd v d d N4 lcoa n nsr d u
n
,C rtf osn k R r5 en v en Eitb a 5 poi n
a O - idit e gn t ni o( y vr nso e ('
e rh s co w le sonn l
I A i r S rzeat n se aCl f f c a IE oir pr ec e a sl epd u VG u io d n r n t s ". ri ono niosa n EA til a ef o .o ir esc avdeh a RP nt sl it rc I si e v w i x cop r m eudb o d o gt f t es I s ran) n) ot iti ni ot yi u i nusC m eea c R oO pn d e l vo nK oi a rrdi sS cN e nwd sl tnryem h/r r panl a( ( h m Uaa w cAGo . g e a ph gt r e n eV h n o rst p "t ur ind ny iea v i d no ngn TTt wr e
r ds al
". oa v r P N
sr/
yass C".r l ius rp h e sg na e rn eiA ps yt oec) b a pl n5 G ad ea e b g td ti e r ee pl o5 T IO wnd .t - n nsd ne dd . d s u i c( C T l aihst si d n eei gc n n erS v E P at uct e aw eo md v in I oo me xt u I R
C S
t/
osn neg sgunl se ma
,ei
" a td c
r ti at ec ru u
rer t h p st o
d s o ec s
)
l ea l r m ni t
reeon o n p n e ".
fiiK r gP md t e h
t e
E di srv ler crt n t t u aar en nrr n D ois ei e i no no o periai i d ues un f p e
es rn) d on em t ef arn geB5 eq a pu a
N gD uqr d y R s s ee rt aoO edd nn eI nt - De i E gn
.irc c CN t el) eo pn rh i asM r r C ng m n ou r ( niuR oT r eut n e N iim so t r a uf oS eA ( e bdtf op t O wseeac t B . oiw( d h aaoiu irc mc y )sg rW C
d aeh r rDt ad s eu d s en t o sn". s eI n
i .
n l sr en u
.t w
ecw t muo t
as pC".
t on l eet o ac ti o t o t gf ef aarl n n .s rpm r asi c ci ai i oh ntl o osuery eo Wit ot .d e ut uso v t so u 0 0
i t t not co laet m h en dea x n nt e
gy t
t em arr va o
l onr f
oecq nri eu d a nm or co d
qen ed ara s
eu redeo (i etC o l ti dnf N
it i
a n
l et n ei s3f rne f oh) s ac m arnar neor 4 n R k nt r 0
2 ti a
,o n .
rl ai m1i e owc t n oi n
t osIS cis1 m .
e e
suw b l d i p nnC( Can t e
Y inq sdo sa b al t8t u r o h)i ro esaei R n oha a2 nw se si clC gi d R
O G
/rrect n
gnnaem erna Ci F
s r
pgo ni n l 3 eo la7 / ml tl eh ot d r oas".
et .
dl nr nn e
gn . epm
. ot mra r e
E gg rr yt yi t t0 ro u uge i o pl r p T
A isii yeo nf nwi s3 af Af Acit ssub so C ess nff aa aad nC p V Vl st erooif t A B Deeaen Mr Mrd I I eo T o T aee D errh n n
" dd mri " c " da " TDN " n " cdl " pgpti a T U c N S i E R if M O H F ng C N A S L X X X X i T
N B s T
A R y E t C e N f O Y N a C TF X X X X s E I B r
E Y
IL o O B L A d P C M I N e E LB X X X X X X X t PW a l
P A e r
y MX t
X X X e f
a s
t o
n N
N N N N N N N d TTIO B B B B W
B B B e NA W W W W W W t a
)
0 y 0 t 5
fi e
4 2 a 8 3 2 2 7 6 1 . s 3h 0 0 0 4 4 0 .~
0t i 0 0 0 0 0 0 s
- - - - - - e 0w 4 5 6 0 0 8 t 0 1 8 7 0 0 4 a N 1 d 4 0 2 1 1 1 c RR - e - - - - - - i EE 5 r 5 5 5 5 5 5 d CB 8a 8 8 8 8 8 8 n NM h - - - - - - i OU I s N X N i i N CN W( I E I W W I 5 5
/
0 N
) /
T d R N ' S E
M 4. nt 5 E 4 o 4 L 0C 0 E 2( 2 *
,lli l il
,1' 3II{iIl li il lli l J
?N- -
) 4> '
~ O . g 2 N .- e r ( s w n h o -
e t e i n " t et d
.'.j ev e -
R E
t f
a 4 ni me t.
at o m
r o
it) nn oe t
'.n le t
ad ue 5' l I
p B8 0 ur of encR i m o d qn p M d N c dnrt gu5 t t n ea a UF e - ot ,em r eair( ar- .i s a d o N0 m .3 d n pl st ca ei h al re0 esre es i p l v d n
N5 ol1 adl oh f e o _
O - fi inift me oc dn o ". iD ir f e tf on f g a
I A rf5 rearirndcn r p o S
I E
$ pn- 8 ept eefi n t eep sa]
r e e C u T s N
F scb k ie l a
em cEaM rw u -
VG 8 N idd Q B wa EA rn n RP i s 'n oo I
cicrah osso i a eren ,i i ro t
grd[C oP f a oc l
ti avea el e r a m -
wi:
et l ndt gneswsnot r i a s sr wn i
eh m A' -
ert e) a ivm aa iomweti cce se eh l l5 r ere scseinoeew eeol vegrf o yl ) i c ptt p5 g l c5 ve onuo( o roe dscvev fP au5 et eeoe 4 r fS erent e nN( r ) pi b p
- l n ,arr res c a yR ca ~ P N
O aI c : n gf l h s o epeed btl N u l n . mbS o (
Ei e". G I i re on at e u gr". rd Ofdmn f eoo h T T net ii yc rsdo . i en f e hgsrunSi C P hho t vli guaews sno w) t E I ctN aiinnsht l eni ne3 une a R er( cerhis l hi dat ri0 oic . u e C
S t u icacmesuca mam ev0 n ift h t
E o f f emerrial t iritophvhe t
ner ce- eeSriscos D n o ". c r e t' pere f T .wd at o nr3 o 0 t u w i n -
,Nnr po r l af c y1 oao e -
N hel o ,l pun l - ncssh -
R s e sr.dT pu .f ga qi gl5 li t a
E n .c e d w nn re i na8 edAh C
N omn l ew l eesio adr i r-eae rl t e r
e O
i eo thc are cai)
. ehit mi wen au t t v .ncvsrt o .ga C
l at udn t
i n .eco h crt sr n s ei oi
.rxfd l
cnt n
uar h
u o l
onI l e gs a
eccnv r
eseor ti e
% i r
c cee ct erol end oa nf ft hi '
l wm eee e al c li oe th ,d g) a -
aet t ,r ,p ,cano o o enm t sea c -
cir va ,.ag negnt n hii on rsn t e h
tes a t atCpl Rl i
t a , -
0 rep s gti h u h n s nss r h 0
4 ere g D gk ult oceea npbl netbh osa ceh das e i th t
aSel , pw i i n
ne c m ws ,edeto s i
0 i s d r ,-
avn pn poi t oI f ns 2
Y -
hao
/hi atdsade rse et e tC orc np i oi tih adnrh nooc t e
e e t der ,ecans r a i e t f !.
R O ipsc tl;) nl nuIt . ds ny .
ntT ea cdagw a d
G ru n sl eq ii n dl nac r E
T -
per kt g p qiii e ioel vrd .mi et dsr ye I u-ce ocib cif nP R e p'
rcs
+>
A s - r g x e a s ul Al c C1 t tii oen ee nop ' ca A C B
U Fh o DrsEnxn0ou
" cC " p a(K e a 7 d q "
V an T no R3o NCN
" ' (
I rdaC CoorU
- wmtN t
n a
T E
C N
M l
i A
S R
O-F 5
N L X X
~~
Q
~
a_ c X
s i
f i'
i c
n g
f- ~? e-T h B ' -
T R s A E C
N t
y A *%
e O ,'
- f
~ ,
C Y N a T F X X X X 4 s E I B ~
E L r I
Y -
O B ~' -
L f
A C d
- o. .
f E
I L B N
X X X X '
- e --
P W a r t
P ^ a l
A _
e r
y MI X~ __~ t ~-
I X e .
f a
s
^ -
t o -
N n -
O ,
I N N N N N d TT B B B B F e NA AC W W W W B t LO ' a l
PL
- )
0
)
r' e
0 ys -
0 0 t n 0 0 eo 2 1 fi 2 2 7 at ,
3 3 0 4 sa .
0h 0 X 0 Nh
~
~ u 0t
- i 0
- N Ft sl ~
5 - 8i ea 3 w 0 0 9 2 0
3 0
-w t v )
N 1 d 2 4
d ae 7 RR - e - 6
- 1 l
l e c 8 EE 5 r 6 ie /
CB 8a ~ 3 5 - r dr 5 8 - 8 6a no NM - h - P - 8h if 1
/
OU Ns N B N - s e 0 CN I( I W I I( 5b 1 5 (
/A -
0V
) , NT o -
T d / i N ' Ry R -
Sb - -
E M
E 5.
4 o nt 2 D
L 0C 4 E 2( 1
- 2
3J7 r 1 1 4nENC 1
. n n a h".
c r
a o t n sA wof f a md yco oel ei sk nht t
f o t
M4 ne *tnClNd coca on
-%C c' . i h i I 0 -
1 A 5
I E
' i . Q e.r eu n
b aC t
o .
it gt se el f
o .
eo n laE oerci P ecti ud eh d e no s or f
m t
yo i d r e
VG h c n d gi h cueh sn rsnh EA a totNCfee qb iceI t o t r dt o gi t RP * , r ue di ea r jnar
.f p oc nv l m fEf rohil ait u A
h n a wr so a t wua qn Mwnf t o n oo e eh ai a ic t r nf gehR ck) eo rao
~~. lvg el eni ne w k n n gt A i c2 ri
. ec aa Sh o( t a.d mn st mn f is h ptF wl di td os ei rr gp t o c ac - e C
' Ca - o n b ond a nt a d a h ine ~
N y O m a
w D
ims k f.
ct l ope nl N o. s da da etll d
I or an ou ar I r fflp eo t h e/
T P
I R yrrh ri f e e t di
'nc r o t
co S y E n m
l u a
f o
P E e Oh sx sshf a om a Etec nt n mes agnC rih c
urt iwn C gu r
D o on t aeeecf n cd S et n t e e Y yaa ae E
D cn ne ist es E NA ea s rdrn ueaa t
et eC I nt inli sk om d n uh dt Eab ein R
N cu c eC o r .
on d ears cnea I ni .
nmao l ut c E
.C go h t )
f io s
,C oih rmt , .
gaht
- e. gi iace t oDr ind .R gt ) Pi oddl si nd e sN wt oo sl S ea( ina m
'N CdS
.R l/ aera m g) o
.o w
> .C l n gv k r E e(
seshti h
'g n n ecue q hiS t
l cs(
nR ct osP l ) no co t snn odR arp". af f c n o e gf el iu n oc fiS e
d(
h cpn ao rn ti oe".
tf r f irsupa eic i maf r yE P
n w s ".
l ati u pbi utN)
S h s A i er uae evot bOs i n d S 0
0 4
t des r".
e V)t tea
&m t e ah ut o
s est ne t
ined g
r no e r 'R o ta roc noene aer k en rroy oact
.( -
enn 'qr Wc 0
2 iio Ar (o eu li o gl nehf' it n oon Eht tl l *
. 1:-
Xn Y' f gi i nt t ea e
t sn n i f dS a
o cse ydv el f o
T eEd N xcoenc dCiail sb es hk eiQ c '
nl R
O n eni c o l' fl r f n o
l ern
.i edf dev vsoo neiiru aab yt u t,r ea ti G d gf eee s ceil pi esf m o E imore i sd m i
iii l nh k a st opt roey u] al r a sc l nt cn t sc fi n Ai prn qc f o C Cee eir a nN n f vee s w eo eienf A D RDp B ru LI UCo Oedh ooef h n Ssh on U N" s " Gf "C " E c " ri T N p n o T A " [t cI T
N S E R M O H F C N A S 9 X X I ! X T N !
R' T
A C*
Ci N-C YN -
T F X X X X X E1 I B - .
E L I
Y B
O L A .- -
P C .
M I N -
E LB X X X X PW P
A g X X X X N ~
O I N N N t N N TT F L B W
2N B Q NA AC B B W W S -
LO PL
)
0 s' 0 0 0 5 6 4 0 2 2 2 1 1 5 1 3 0 0 4 h 5 0 0h N 0 0t 0 0 0t) _
- - - - - i0
- 7 7
6 2
0wi 0
J C
8 3
0 w0 7 7 N 0 1 1 d I 0 0d0 RR - - - e - - e3 EE 5 5 5 r 5 5 r CB NM 8
8 8 a
- h W -
8 8 ad
- h n OU I X I s i H X sa
- CN H X W( W P X(
)
T d N '
E M
E 5.
4 o nt 6
4 L 0C 0 E 2( 2
- l
UF N0 t
a eee s
no n~ mrdR aS d me nrh nl
,t ss c ial ese ss N7 O -
h h tT4^.W'*. "
- i oc t e
, +in(
g - ih nru g ew ot v
ar Tii nsi E cf oT ne E eiiE ub A n : h w" ae ul - oeJ n I .h ff ht Hdd sE S r . _
i y )N o - s S o i H 'n d IE eel A%. S.j!i o our C nn
) t n
ltl sMvS al VG EA c, r 'a I al v p r'c o E so
( mn go i C Ai( e T h rat o u
^
RP ou:
c qt er
'a .em n e
rt n rt sis ena s
D r
e '. )
ATR D P wAh T ac oDt n as aso sdam cah sR N .C n o
..m.,,w enc i h ye5 i
CdUk eti
- h nm ' yhi no t cl bl ( E eN ul t g iu s- . P e.
. , . t bt ( cn o oeC 8u, d osea n " _ @, - ns ,mr Mm edht sf .im
- 1 i*.1 s%
leo f ~
gei ntt ee . -
7 9 c".
e uat s id eso r
m3 A. N %
% a g p
_'N O st a er v
es iimsr o u a nCkor 1 pd n
se i seweref r d en 3 ; I T rog % re cdg, h w i oi r ead eoyi r
.~ P pf n pni X 2. e nu l et lo sen yNp j l
d xfi ai uaf r f q oeh gpe
_M I
f eel :
l s
.J. . ^ .m f
f su gs n gn g f se oar t t t nme aeniE n oec y S naa R gt e 4~
- e siw n rni d h
p nd rav o el a e a.'
l Si er N sda e
D.aw d r v tl e cpd _ r ya eigus el u nC g w isu ewPh i sstd e dt
.h Vie d 'e y. ee ein i . 9c l o csnaedd w-E C
O C
N t
edEj*MY({
os rw 'E pm a .
"y e pt loni vd mil -
f cu f s
'f eit do n f Gt E y ri
- bc c
i c8o r
e'f 5l
.l d
eioh nd e d s ansdt sa it oani auesat i
N D 'n a a, w ec e ee dt ol l(, oP s wro e ceewn Ff N e eN dssru o B ot r a nas t tb a n i g q n c)
.'erBiW t l
m yi t t h tz ' c sg a r o
ihc aa mod a o R v civ0 t i i) hc . tihS
.I ot r a l wup tha w si 2 t vn
- or
) isl sut c(
riwf o
.l . o a n Piaeb ai
'0 fl u P "c e x
irwe t( sNe E vre mh -
0 , '~
- l ul n ay l
c t " d sl k cl N C an c F B rvoeoe e y s r w ".
0 4
2 aqh o u gt C a ni a
n e
m ehS utP e . - ef cgo on i er4".
vo s
wnon El o
- d c
(
t n el tfT s gspanE n mdiE o Y
idd nouus n , e s N can sfi o ret nire Hi
)_'irToac R
vari g s g sf - h o eoti at n ewe esSt a
O i a I o8 f ci c ct bne matd ui G
t l n s 'R n r1 2 o t xyua em erf eshAc E
T Jrrc o
D e C N
a
- e- k2c na et rm it r
's m t t er gd a t stTi a ci Af A t e M . Mb5 c1 l el so tl a neee eDi C nnvd ) [ )
anf app amdfd m d A B A oen
" csa 1 [
'(
,3
(
.d E n1 s.8- l ev a sd a ~ 'h T uon Wme qcf " iD Miaf nif o
" t mAat oM T.
M f
U S
R
{
i 7T de -
,u'
/
. t O . #'
H C F N m s
_b A S L X X X
'A.
T T
R E
N B '
/ . i
~
~
C
~M.
O N -
YN
~
m
~.
C E
TF I
B, A
+ x~ X
- X X E L ^
v~ Y O
I B .
A n .-- L P
M C .
I N LB i~
X -
1 X X X y,"
E PW -
%A".
(_"
pc y w- -
.\ '
N 0 1 _ X X 1 5 4 - -
+. (m. C N'
N 0
N s'7 .$ M M M TT1 F F B 3 F B
0d -
0 n __
- 45 a Z , 3 7
' 0 1 0 0 0 r 3 .
C30 -
t6 t3 s2 0
9
_1 8
8 2 0 5 e
N .} 9 - -
Rt E0- ue00 - r00 i 2
- 5
- 5 8
S M
C6 5 a63 G 8 - Q NM - -
OU 8h40 M
T C N P ,
S E C N_' t h28 .
E I D
_Q- ) .N Yd ,
- g
- ~
d
^, .
- 6. 'tn ,
f 4 o 0C l*
E 2( ,d' 4 '
~ -
r'
UF N0 S
E d s gi
, o t ,". i(
s D i cnt gnr o N8 O - N leiiat rm nee omt p".
p
- I A E f aer r r et os S meo are r I E m eenf ul d e VG o hhi n l c ee EA r t c gi ooa k n RF f sn rri ri o E e tP v ag s
e t r i ao r n o ,n mne v degm csr e eh o t e rd ie i t oo nn ecc cen an a
c l psa ajo e d
- r pet s f oc ns N ust a rr ar O P si a h eP s e I N vh t u 2k T B geCl n ,o r P W nr C i sm t o I i r ey i w R t a
eoo dh n n C Dr . nco Ur S h oeP ann o E t tbl N aA rf D oxl B nr o s noiW oB f g N g F v i . n R n) e xt) t - n di E iO r , oar a o es C wN aen S cSi s u N a( uf O r spl Kd( e inD Et am n C d l mov u go
. aati . N r re os ux nesc e1 mE o f o inc ee d o a eet cnn b r np mrgri ii o er vup rFatU on n eh vt r em r
0 o h o e ak 0 f od dnereen.cn .
iiwh t
c t so r
4 e esr t w 0 yt veh rr f nu n 2 t c nt ae f of s Y u on c ei ire R iat r l t a ssn t o pk a
O mt no f an G us s i oc oz 1 m qn eymi is E' o tl ssr k na T
A rc aenie cah ith c C o- dmavw ag ni A B os pi reo L rI Un U Pa Utt rP " oC " w T S N
E R 1
M O H F e4 C N e0 A 5 L X X XS2 X T N B T R A E 1 C
N e4 O Y N e0 C X X XS2 X Tf E I B E L Y I B 4 O 4 4 1 L A P C e4 e4 e4 e4 M I N e0 e0 e0 e0 E L S XS2 XS2 XS2 XS2 PW P
A g X X X X N
IO N N N N TT B B B B NA AC W W W W LO PL
)
0 O
Z 1
1 1 1 2 1 0 0 5 0h r 0 0 0 0t
- - - - i 5 3 0 7 w 0 7 0 9 N 5 0 3d 1
_ RR EE 5 6
5
- - e 5 r CB 8 8 8 8 a NM - - - h OU N N I N s CN I I W I(
T e
N E 7 8 9 M
E 4 4 4 L 0 0 0 E 2 2 2
TVA EMPLOYEE CONCERNS REPORT NUMBER: 20400 SPECIAL PROGRAM REVISION NUMBER: 2 Page B-1 of 42 ATTACHMENT B
SUMMARY
OF ISSUES, FINDINGS, AND CORRECTIVE ACTIONS FOR SUBCATEGORY 20400 Attachment B -- contains a summary of the element-level evaluations. Each issue is listed, by element number and plant, along with its corresponding findings and corrective actions. The reader may trace a concern from Attachment A to an issue in Attachment B by using the element number and applicable plant. The reader may relate a corrective action description in Attachment B to causes and significance in Table 3 by using the CATD number l which appears in Attachment B in parentheses at the end of the corrective l action description.
The term " Peripheral finding" in the issue column refers to a finding that occurred during the course of evaluating a concern but did not stem directly from a employee concern. These are classified as "E" in Tables 1 and 2 of this report.
D e
- L 0107A-R50 (10/15/87)
s
?
R]
i_ .
. 1_ _
l 7 1 2" rl s f n oa a en od a d 1_
- yV Af r r
w ri na n o t e n
onnc ge f _
- t uh R l I yn os t t o b i ei n d o r E2 w t e f s cinin e t ed en a uo B4 M
e ,1 c nr1 el e e
ycer t eht s)l t uwoso ui e h
t ni nt z ab luir a n ol e i e c e ei c e . eeani n
e . d ve "J f
! c , wb n i rt sleca e oi o t l p el nz sine otd nvnpvt uh nrb a ai x i a n t oa h as.n i
- N2 O -
IB itPsnnhbt gae(
hroiti aunl ai hl vOii etor nst ace eaiez d gh r ,etrual osnf cpl eith wixr i
st saint a st gem m
S Waph shoo rh ghli si t ooeeat sr neg I e . estt nThtriget rT pnts 6 ni xr aoot gn o m Vg .l Acrwep eiso aioh nx o omann ge o 8 ett eprt pf rnanr
/ man os f ool ap Ea RP s u vs .t ztPtP .crmc 3 ezeeef yc hefl p n .N e si e s di r i N6 Ot 2 vi m h h f a dt i
o S fai t ed r e icapa e n o r w O8 n
/ o ss ui
/onttt sl at e 5 rai nren ,rnn eae) t f o d t o yt n g e e n e2i .j 0pgundoa esp w m2 _
c o i it niarrlih1 ttdh mrriniermiN omp0 A rl v avvo cat cnac eioc atl othDpeo l eoid id rug nae i . h es pcfit ntlS e agstnft aeuNani mdhs t gP rrli u naseP v vancaoc h o i lt nws nN e e r h y r di m y v N i i noa a yt f f d l al a e oiO e g v c c t cn se _
t rac nn l onsana ,c t o v a e sii e a d d d1 c rM roortf e at uonsdov g ei nl ehl r eeg 0 e a o aii a n o h e rniot er pnhsa dwi gtt nt r dt et tea tc ,aat cnwp uot nme b enaain4
~
r o ee rtd c l aal cl z z ci a h f 8 c i6hma ee zl mi g e d nsaviddte0 g , nt raorti uiism2 _
C t n e uii u f v gf/ yiaevn nnixariensnll ae i t n n aa n ni o u O 3 e c ni n ei o eegt g u n i o o c gD nor nro o p a s g g n g p r e / el gi f 2siati ro g idie l - i aoetsseaT a t d e cd s n c t nnnrnA pptt r r oi ph h 5 h o r n e e n ecah ui o a c x o o o o a C Uasioonsatt0t poirbo Lamt nmpmaE cccf m(
N Q .
~
S a d s e , k n 5
z P a i6 N y o e rw fi o
8d r8Ol wNoot _
c
~S 9 eoe/ w t _
N 1dtt7 eeg sao t _
O i c0 h n n .de _
I l vda t i rel e T iiery oreut vd C tdt ab nteesli e
_ A n rh ,ihdniiicn ensltt _
usoc ap rt ei g bee E '
V ,
t w e e e i n g n gi r m I a rbvwgnE nsre T hs e ie inol C t ehdwds teocp E icl oesf cbp m R0 mti uHt aoe jeee sri
.R0 riho a O4 i vwc del orrhg _
C0 D
2 fi ntf ocooeowt n".il rerP o r asndoit n.ep BNY s AR g ca etonl i ms ot r neea .buo T
M ,GO in n
, Ornasoeciussor P aozrcn sdersg fSE eGT d
n i o Nenie Il ne nb eoh ecigat evel HNA i t a
c ,amrsthota n CIC F d u s gu e r t rcnee pearm ._
ADB t nnt rcwed pno jmae reno ds TNU n a J.
TIS e atdb g AF R
me um Aomtnee Vft aait ,d a nodPa nPn
,O ci T rh ti se caNa SF oT yaT yi s t nsi Cm E
U D
e yt p bie d v ngef s deivires n
S S
I io es vn si ld nbl ewa r.lietnmsicoh i c a tracpc s t e t t 'AV sp oi a g n sa esenT F ss i sraurrpsr ri O ee tnen" a e e ai ei n cR aova etdwdhdde t Y x g p e m gl r eh R Ed i ss ncadNr Pbt A n t e ei u u e Q a e N i g M sa s r gl e n qt S e n U r n M e e n gb da li ce U r , veon l aercf esr S is nhmisl erouenet ue qr Itasaahcf ndtds N
eu Q . .
Rd S a 1_
e ec ro ur tP cu ,
rs tl .
Sa _
v l o n ar hi np sc iA op ii n ho r .
t ewi i a , r s .
zs u , u i w t ef ne ai cmn uoo gv re rsc t r .
- OR seos bt s
. s - l m e ) '
e ausc 7
_ u .
- 8 s *
- tr cdaro ,' /
s I
- 1.**
- 4*
ed e p gnl aa n 5
1
/ _
- 0* n sg 0 _
- 2* ayei 1
.t*
- mdms (.
ii e
. n* setd
- e* l e 5
- e*
m* 'A V noh wme 1
- l
- T ust D
- E* 9
- N 9
- Q . 1
.
- S a 2 l !I[il
E2 ie M B4 rl s Q rl ege S eg mf Go enr niug n en ni isdn i isd g ei g N3 na O - nacr "a e I B e yre oe "
S Sb I e Sb pn V g E i n E E a Ddgg o Dd RP s enn i n Ncie t Nc o Ear c Ea i l ee a )
t f pet 2 fpe c oeni e 0 oe A ris v s g i S s e eeny t ee v . mreb c .P N . mr i
d ue e1 d ue t e l wEd r 1 e l c r o Oe . r40 r o e i vs t s o0 i vs r u efne c24 u r q rroer 0 q rr o e uu odeed mu st2 an e
r uu od C r eD fe f eml e e e cupc emT n eol po mea alC n
o eo hr o h rour Tpv N T pvsp SE( N N
. B . . .
- b. c W a b c w ) d s w e A e , k n e id V en , z ,P rw o id ve n ve T n nrr 5 ai6N yoe fi e
es ,I oue 8d 9 eoe/
r8Ol wN oot w t c ru )
i S ru t vg en 1 dt t7 eeg sao f Ol eN N f Ol eNo O
I seo es P e N n inEtinwi or l i
vd a c0ht nni .de reie t seo es t on P e N n n
ln t on I n l fd H e iery oreut vd ip T
C ah g o poee cr eg nn itdt n rh ab nt eesii ensl e ah g cti I,so i A ictis doe P r Le
,s icsue sedw6 gt
.ii usoc ap
,ihdniil rt eig iee tt cn i doe s P r L e cs se E t w e e e i n g n gi rm t
ntd eA p i V ntd eAp ime 8nn a rb v w gn e n s r e i hS d I I hS durs/ee ret ( y T ret ( y l P7 m hs e ie inol C sah n SodE0ne t ehd wds t eocp sah n So E el tft a E vnO al icl oesf cbp m el tft a E R0 orm D a n p mti uHt aoea sri ri orm D R0 rl uen o r eism rih o jeee umn dii epo o
N O4 diiepo N u h ai ivwc d el orrh g C0 es neo E o "d t sh P d fi ntf n " .l ierpr o r asn'd tOn epi ,
es c
neo d ort ,
E 2 c dort . f e oeen s f D oeen s f nfEh e ocooeowt ms rrg srs BNY AR s
g rrg paa ,ioe srs osioN al al yi ca i et onl ot r neea .b ou paa ,i oe os s
T O n gNh c s mtf oa O r n a s o e ci sdersg u s s o r gt nBtk o gNh c gt nytk o el asout P aozrcn el N ,G i qe N enie ne evel naeW rr m ESE d naeS rr ml eo nb eoh e ci g a t ih rop u MGT n ih rop uerMeed Il HNA i rt srow l wt mS g c , amrsth ot a n rt srow l CI C F e iof rw o s u dusguer t rcnee e mof rw o ADB esrF ee vs" .l ,n nnt rcwed pearm esrF ee v a pno jmae reno a nRi d pi TNU TI S AF nRi iCf gD n gsi d pi ea v
.npe r
B ,e8 I r/
se6 eNa 5 osi vPEin ,n Aomt nee Vf t aait d s atdb
,d a nodPa nP n g iCf gD n gsi
.eavr npe 8
1
,RO ednt me tdw0l t T rh ti se caNa ed nt me td s
- SF ninavl sr gen yaT yi s t nsi Cm nina vl s a r a xi o aasnnh o yt p d v ngef s saraxio a E el esr e U el esr edPiit c bi e i d ei vi r e s S 'A s e p sen st l nE a s s
ol si l d .let nmsicoh' ricat stettA
'A s e p VN n s en st l S VNn nbl ewa racpc V TCi rnco t I TCirnco tteP at a a E geoxc ashE u oi a g n sa esenT E geoxc F f nwie TO ynn . israurrpsr ri f n wi e n ed b oas t nen aeeaiei n oreot n e O
Y oreot wf r o pad g gei rn ea . odt f iMe r
aova" etdwdhdde g p e m gl r t eh wf r o pad g gei r
e R e erit s w s eit u iss ncadNr Pbt e erit s w ish at ae sPecd cd t e ei u u e B aeNi g ish at ae vet escd eeE madul ee s r gl e n qt W e n O r n vet es cd e Mf el ol ei rd ajc oo e
veon n gb d a l aercf esr li ce el ol ei rc cvde r
e U rc cvd e eiSl p nh misl eroueh et yyunnh h S yyunnh h uE oenrr Acb niI t T AcbniI t T gD v r IP p It asaahcf ndtds N ,
. . B . .
b c W a b c t
s i
- r ,d r ,d x syo) n h syo) n e enf sa c enf sa sa N s in sa N s smeC , e hi smeC , e a lE) r w '"
a l E) r poc(s u n poc(s u oy R d , o oy R d
)
d dT csC ee eei dT csC e e n eD cb rms n eD c u a wc( o ueu a wc( o r
n .ei ro pt t sf crn esit s
.ei i esit s t vd vot ueo vd vot inens n i nens e gd ne rb c t m sar e o sa r suos sh eu i C sh eu ie e egq
~ ( e egq rn ct s cynne
. s cyh ne e l e e N xnt ar ey N ad sc xnt ar u Q ea h ne B i nd o ea h s S mnce g ih W raa r ep s mnce g i s e o i gn s I gt .
I - i o gn n d - gyl i oena . ede ad n oena .
1 kt riha nn 1 nl sg kt rih a r arcd yai aeei r arcd 4 oh e n n ,l 4 mims oh e n 0 wgeena a m 0 wie wgeena sntd rul ngr 2 rul ngr mt a 2 eopii o e o piio se ue progs m t progsm oir t n
'A V soh me ah enee n ah enee oxt Pt ped m T e Pt pedm T es e Ti st m m e e . .
l . . l E 6 c E a b
B4 M; -
Uf
. No N4 O - .
- I8 S
I e V g
'E a RP s n
E o
it c
. A
- ~ e v . . .
i d d d t e e e c r r r
~
e i i i r u q
u u
. r q q o e e e C r r r e
n
'en e n
o o o N N M d
e
. ' f'.
t .
d n t
,A e N rr res e o a d Bt oo acre n i . .
.h er s-r .t Wne . ff r
. eier g t l f t ;ere e .e l tea c a o l hib S m esl - dems t e ws o ccn isth usv eat um te ;
N et pgnh nn nl uais sct rro' de t c qu O ncmnaT go ib oi nrgr aejg t er at ail en I
. sr ieoi ii . psl oi- er n v pne sgp h a'.cnl r d T y o y gj c t r
.st a een , sri )on nnp r2ih a el C
sfb no re sa n nb ne y oaa s dct sgel awop A eeyd ereoet ac etouop e c p oi u nrfil(pd i t ogam ch g
erd neseria ph pnc i l toF Ca n i. t nraf cs E rht ee t pi e r n basrt s s ncetu ~Nen - i ul ir V eti lmne ugjeu ynrt et c suseit ng 8 pi n ey d ane I w uih gsnoem en mdme n a n nsa a yt r' Wir pe n1 t noee h T fi sl t n ernm l o dso 0a aat cht cne
. C E
h oob sp iaiortt ih pi o gc t cee i n rt st ti e gh s s o s ti c if d
eon e 5 0nt srm rr ot a e a R0 wss ct oicNn eeaaic ye sees wti AiiReep ,hth t
.R0 '
t nns t web ee cl l h e s h h e m h s y' o g 7 nCkd s r O4 C0 "s noeiEi e p e d N nso jW na t egseTS rnrr l ttd(tat .
i s l sn l ne 4 ed' uFmohareek g s pf el e
2 rmsb Doereat i e- a ,iw 1,sndl t ao dt nh t nio D
s eee el rday d m c ph a
i ssem.t a nene s cx Ati nir i r nligon au arret TBNW t sl esV nhabo 3t o iti eh p A
O g
n ine mhl aebrfE orNnt c ei hait gsi oT irl mT nirsfet if 0cr ai ser ssh l ce N ,G gce n e n yt l t pe greeanedt v dsl her i
.d cmtt owene 3i p E5E d nit e e ft eDoua bf odesua eosAp eo 4f n ghhoWi iR MGT n essssnynesi ii n l cy m) npg it it nt i e d eC HMA i a y a r gti h r r o t v m', loo e s o .i sn Pdu waa l s ecF ClC F nbsh eii t ett c o e gsi d .ccgei E oo a n h d ei .l f se ar A08 g pesl g es . ert net dnes t nrr mht rt nnce TNU i es nsinonis S p si r a nasenee e P d eanelf e TIS shiniabitidn gossme yt r a eni l e E ei sh oduortt oee AF eth gg i d g o e hi a ,tl n 8 mw ret 3s d co
R
.O d
t T i n s s u d n yi nt eep l gtl tscai ar Wosn ei 0. enhai r d e l n e sernleocn eel s etl o i prl erg gt r SF mu li rNs be c a ni e oj e n d o n t E eo .dt e p n gt av eSenor il gccrove nei aufi o 4.. p a soshdrrvc v U regee
.S S
tbm saeeeie y hhjgr;sjd cnsiicci seid it eWhorP n Ti p t e nis aesirnp h redoo t
rom ee akt 3 ml aa hg Pn) i t E o s n p gi renh sbn i Ropnm
.I sett on naoor ga adh cad f cevt l emeftC aa
" l reeg rie n .cnt e mntt onllt 'eo h as 0. o a i acocF s h nT F
O dati bonp hisprh rt si et Edmia eef o
,T h y s
4tt s
r r ed e3 r u(.rgcoen i Y
R haegd det ant
's n io t
,d e ,t po sat o n
shti mssdg ei y o n s
,t ea hl n i c iba t pe d si m e e
.srd Pl n EeI
- n "
snp: t s gi r t a xsl nreaseacr 0inaaegcishae 41 Senct enmmt ct tl smit eenreen Sng As5dosh enisa 9 El gesseeese sb - t r erbdoth ni Eon " r nco nafl P
U D w i ji ososdesssos sttijt yaht oo ce i pctib St csop nwsvse gm Dsi rr ore erepNopg dact rg peihi S Nnsrsnryysri saoh e i o ai e l ono Neu h rvp8 rinf onnoon Ek a p a a p s s a pl Aeepsr S ph d r e t ec E pd T eoAWppeomainwe d e f y
t
- i d p l e u ,au n
g s
.q ri g t rc os n cetd f ssfi ahen g
aioc a
rt t o
,a l o f
a nt osf nnl d
)
d i
rnwce oht r oaae c ct c'n i o ,
e o et ,i n ni .
u t ;l pn gl re ht g n iI asi nat m ce .
i n ua g iccg ere t ond li ea t c(
n m gi l n d nl r s o i vli naef yil C d si a d ah ,
nde
( ned u h crsd a n s
e adnfl . eeie men N
ym I ocs nmh t t h o .
s u B W t e c ei e nm ,
o srot e yc ot s) o rn s '
iti
,t renif t oeg I
- i sfbl l
yiamy s ehal f pto ,ib a s t pi s
1 bscees est e i e gt e n si n vnf d 4 sl pd st nal se aoa 0
2 nl seyr oa l so o ,one rob eirr t
praw se oep p htt p l
isceg t rnss Acen n
e evonh u Rotkt s i
Wpcrh ooea V eh a Tdth m '
e l . . .
E d e f t'
E2 r nmi oauiiii B B4_ t wrt n ihNl rt g W M Daooco dt oain Uf fhdf ai nisepll e n No Att usea g t/ asnh oatE ci i C sh avzn , pl bt N5 N oic "g
, 0 - smshiii y s p n D t. s e 1 8 i e t nfti n t. "
5 l e rg hl tbhV egal eAcafid ni oC ,epradoousp n
o Ea otI rrti oiR rosbttNose i RP s nr ipn o a c ssr , t n s c o i s.cfttl ael i i dt onno hA ff ) a t eodt g euret . noe e is0 1
e c b oennsmot i rt aia ecnT o .eehr h v A ll t egco e ceupnraac r
ean/
. .dl t anbsahnN ngceS eP it c .
v shs a yeseP arci e1 i et erm raeemt grb h n g1 r t d ean0 r4
- c f s o yl pt el h ,li n ei e at rcmvre o0 e ebht c n ui b 4 c2 r e l cm d0
'r ureuinricasadt us/memnana2 st o set n i draree an C sb a s t nn e immsiscoge orael D em n u pi snf opw T ui e n lt 'A me n V d nla tr seeheeeoenC seermmtdA al SE T auT apsrdtbP mcba(
g h a t s on n s S l n se g0 t d o i e n t e
E D
dant ndr nsv eti o h a l au m
r
- 6. onnP ise1imN eP 5' rN n ,an .d e ent n e
t y et d teC N eE a o sl wec db srs liv h ssc nl t me t n men shCsoe 0 t nEee oi eer t e yt Qi r h 1
eOireeif b vi .ih ue o s yl ewi aobeqm u pt T ,e t ugt t odsrt C
A sweidnaat l r o p ri ew h f ntbes oiora l
e rcif
_ et hreaeco reat rt )pl re d guA o E ret ochnin ysi ph h nd r V
d ub nt r hocin l ue tlleioi n v w .
s reb t c u
nieaen I
eseupnenrgd occid oril g t at s iot cth o aoati T
C cmea oew ni ne ow ciut eee t ncscr eycna( t crdrt cop ua E rl t ,isoc ea ai n u tl uoh R0 s cml vad aerit a ul eft pb es et r ,t n R0 O4 obedd roi f e amereme f av arrc cmttisaya t
t yoe e C0 er i e c rree oo lt nzl d . sbsll . m 2 ipdtid e e gll ef r e oie N n pse D D nif nnsn t o cb np nrcnkl B o a A m nl BNY s aeali itanea anc nreu o no aiaW ct a oi p
_ T AR O
g n icc a gb n n m i a I pt nl cd a l n o
senr i o ggl c ed
. cgm ei lf nieg l v rti osnt c Neb
_ N .G i prisdi y d g r si e a utB g e ESE d n pesnisl dl nnot wr eav ih ce d nWanh MGT at ao eena aipi us Pulqoht e el ee rot .
_ HNA i nh psdman k r sse rit ui s CI C ADS F
fI cs e i o naonesv omcrra1, destitl nd e i caot mm
_ TNU o recrt si eu
- aarg ,gv oi caoa d uRao et tf snl rr TI S AF enP ff aca az it aieoet e swvdoc tf niPi o nP nx f relf g R ca r c ngc r noirNt n sue a o
.O n f .esnfi iA osi e eCt Ki pseott r SF enostti nnrrn ea nV gorid mk d ennt sl p E t o sinoiadt g , uT nt ps e c "s i e m m garsh so tii s
nu gd i s P U it oi h enrr ni al mne eP S
xaitl csioe i n pscbe al ent nn noeumrN S
ecsaa n osoei v n eo af er se B I
iirnnvn , n cnl rf ee aanCnr F enveooeoea h u i pii ri r m oeuitl eivd ci- (
M" i g sn .dnt it) s 3fsstoW 1 ge miss yl t O t mDOtt aat amy t o vt eeese nt nsaf m oadcpt G a e s ei n i sise a Y
eoerzzozrl rz osya T w mb at yeed r R t cht aii n i nh e e pisr - br C n ei s o hl sbrl d m e ni pt - o E e gl ryp m i pe enn l aaeati l a eep ribca u ou H srdcggrgrt gdd at r eesosl t Asdsf od U hh ereee V enaeh n S eenurrer u ornnlio T oaaP sc Ttd pdd s T rahk sa DwaNoowoF a g h a
ic n n
- u e ngw e n
ont o coe t mb .'
ea e
) v d . s d il ns n e t oan og u cr o pn
- n et ,i si i f nSs er t f oEi re
- n ecDv e o f eNd i
f n C oi
~ ( ocE g s a r k n e N kff e ce u B croh a s W ae t l r .
s l t so on I - ne af io aihd cn 1
4 sd na ina isst t a sm 0 arS eer 2 e bE ruo rn D eqf t eoe h en n hihN T rI e TLtE m
e .
l g h E
i
l 9P]Il;\ - ,7 11 a'3 _
r -
g j$. -
'I V' y eb m
ab3 "
.l ud e
5 ot gvn 1, R
. O '" n e E2 N '- iem rl e
. IS 4. - Q e gl
- Uf^
. No S"
n' enp nip-isu- @
_N6- i g s -
O- f L" na s .
-[IS' S a e yes I
Vg eO . ._ l" n'
Sbre E ur
.Ea"
.RP
. .sn i o- Dddu Ncce eed
, o t -
c Eaoc i l ro
- .t ai f ppr p
- c. e~ oerg A v ng s
e.
v i
t-eein mrri .
.i c d ueer d t e1 r e l wee e c r o ne r e r4 i vsin i r o0 u e gi u q
m
- r. c2 q rrng o
C w st an e
r uuen od fee e
e r.
e e e em me n eocDe t n o
al o hrfi Tpos N SE N
^N . . .
F B a b c d y )
d' g - o s wb-e r s
r g rr e- , n i .t'. n~ o ida o en,n oo .
zP vee tn nrri ff s 5 ai6N rrdfi esl ci - ouer m 8d r8O eeeot c ruc u a tve e a
te nl st e
~ S 9eoe/e 1dtt7 eeun n s s ta'o. rl 'e N o ee ee s ibas N denst e 0
l l vda iiery i c0h t
ii se onn g gi i e tvd es t ofoon nnn l n E t.i oi ifd poee ng nwn'.
Hg rt e e hew aa oi' pshs nc y
~I tdt abnt e E gii e a h oit c os ~ wtth f ntoug C cr c tl o.
A n rh ,ihdftiicn nltt ct naer i'c sue.en i ser rjonunm a~ s e c ps n eas
,'E usoc ap rt eocebee i
d o g gd e s ed w6 nt eofIdoe bte ,it ebirm ntiii p- ime 8an
_ V tweeein a r b v w gl j sre i st s durs/ e er npe) vts
- iit yo nrks ri I
e i ooenol - rest y l P7 sm l ceox
.T hs tehdwdsrrrocp' sadeun S' ode 0ae i ghbcdts l .i ay t rwe .
C icl oestPap m el voa EvnO.a D n hl p ncit nn nea E
R0 mti uHt an sri- rl en ,m= r eiym easeieg el gn
.R0 riho a oesee uehi dt t Oo Nu h ri en mn cgsno
.O4 ivwc dect e rh g t
n.
es ePo. E fe o "d tsr d o ,eui enrI C0 D
2 n fi t f n ".i ocooeowh dn l
reesudOiep i r c
oeitI rr nhMt s f osioN Ped nf EF e l n n pl nct ai s a o o r h ec do s pnen aaino rier ,
sees ENY s ca -ims t hceea .buo padf ,roes al si dt rio rNdp AR g et onl eoP c s el asowt mtfna ei h gi i T O n Ornasoedtossorrersg Paozrcnn gt g Lko hWet s
nu ndena engt R
f5E
.G i d Menie naopvel naaeArr hgnSop uerMerd ml eo oe i rc ee .as oi vm eci pGT n Il c ,amrs nbeo ,tdtaigat n i
rtno(w l wt s mB u ,ng l . wl mng e e gn i
t o e gf HNA i dusguersdncnee e en rw o bs crtni tamo,t CIC F es v s" .l hii AD8 nnt a . no rcweteaearm pnn jmae nRs ,r tee pi a 5osi sewl ah sd eu S epsid yso INU re - ds egsb g iCmMoav 8 e8 vP n aodl o si m TIS gDrF ppe 1 ,r/ Ei et AF Aomt neemieodPa se6eNa sct enc gt v
/O R Vft aaittsv rh ti rsicaNa nPn n edf i8e revl r tdw0l sr gen' t st ri acendhi iNsen n erd s an gro si o aasnnho T yaT yi s a a ti Cm rFepa SF E yt p ,dv deseires p cfs nFisr edPiitc weeaet jnhn . eHhu S
U~ bie ld .li et n dd awiettr c o h 'A 'A s i VNr hst l nE s a s ol Soicgrm E r g ei o e e Tsg nt n rica iaL ri I
S si nbl oi a g n ewa seM d pc senI V IEesrxc Ce. ten co tt ePata ashE ynn.
u Dpnmsft e(s aey ndm og s .ot f nt oe No F.
O israurrtFr tnen" aea8aei ri n orinfoga dg n ed T 0. b o a iMe s Et es rt)b l s Eeego htnh Y.
aova g p e m et e gl rrrl t ehdde eh wfnldei rn.f ea s odteitu r ,densie 3 ewe ( st m s si s ei ym e R iss ncacoc f u e NiPbt e epet s w 7 n nmne tl srl te eiuu g i s nae sPecdcd sb ob
_ m e
s r gl enqy nnOrn verricd el eemi eeEmadee rd - ul ajc 9 geoeol 1i r pt pp yahf u semssm
_ . e ngb dlk i ce elSl p oo St cro u
r veon l awrwfesr r ch w ad e nsh oyeo saer n h mi sl eeoeehet yt oxnh huEoenrr I at csrc Aeept S ItasaahnwNdtds A c o p eI t T gD v rip p N
F B a
.' b c
d
. g 4 y , -
ds t d +
_ ld s e ea . i n g
ies r ,d x ri g wl s syo) n e os n
- n e enf sa .
fssfi usc sa N sd eo smeC , ee g aioc a
smr a poc(s l E) rn nt osf ii p ui oy R dl i oht r een t
dTcsC em rnwce o et rmg n eD ca uoi a wc( oe rr t sl pn iiasi tss .ei ua c e esit s pt n g _
uhd vdvot s ond .
inens g m gil n rc sar e ne i vli ti e ,
shh sh egqeu i b dsiad u
wt e r ned )
7 s l c yh ne eo et adnfl .
i ocs 7 e a ,n xnt ar n ys nm 8 u N iei ea h /
s F rm mnce g id ge ittileceI.e 5 s 8 eon gso s
io i
gn ne l sfb .ts 1
/
l I oena . en i yi a m y
- ari- kt riha bscees 0 1 nes r arcd yy i e gt 1
(
abu- oh e n ne sl pdst 4 mmf wgeena ah nl seyr 0 un rul n gr mt oa l so 2 sco e o pii o praw p 5 c pr o gs m se oep 1 t
n
'A V no d ahenee od on evonhu 0 e Tat Pt pedm T a Rotkt s 9 m 9 e : . . .
1
- l . 2
'd a b c d 7~- [!Il. i'
E2 B Q B4 W S M
Uf n n No I I
N7 *
- O - g a IB " "
S I e n n V g o o Ea s i i RP t t n c c o a a it e e c v v A i it t e c . c .
v .
e1 i d e1 r t e r r4 c r r4 e i o0 o0 r u c2 c2 r q st o e st an
~
C r an e e
e em em me n me al o al SE N SE N
L .
e f B a a d r res y S l s e , k a e acre d t a E d o in e n z P reh eier e il D nd r nsv o 5 8d ai6N yol t r8Ol wc l t ea n l rg e dant
.de eti ent n 9 eoe/ w ue 5 ccn ig en rNn ,an wec e 2 u ai s nrgr sl ibti ii r h eE a ssc o sl nl t me t 1dt t7 eegnnP i c0h nn iN C pne sre t nE ee oi eer t e l vda t i wfOs I sl nce eOireeif b vi .ih iiery oree T a y
ee n ,aa r o n ,e t u gt t od srt tdt ab nt eNdeoe C
A nrf il s e m p yi sweid naat l r opri ew h n
usoc rh ,ind n e hi ott n it ogamvesrg et h reaeco ap rt ei E s nceot eon ret och nin rmat rt t weeeing .t f suseit srt e ub nocin ti eioi V nsey a l ue n l v w . a rbvwgnrdo md m d nt r e I
T C
ena nayvsfl e ti e gh s a out eseupnemr cmea gd e occid ci u t eee s hs t ehd wds icl oesf nseim ieee eusvp E s ti c hd ga oew ni
,isoc ow ea t ncscr ainu mti uHt aoisiti R0 ye see et ev rl t s cml vad rih o a git R0 shh emh snnri r .
pb es obedd et f e amereme ivwc d el n l O4 C0 l a
tt i d(t
,w ,snemnh rie eDmepn g ler pdtid e ie roi c
f avarrc rree oo fi ntf n ".i r o E l er gl rn niri 2 e gl l ef r ocooeowt tib oep D cx Ati n o gt yi b nif nnsn t o- cb np ca i ms nceicb u BNY s i esV nhici ns aeali anea nreu o et onl oebs AR g rl mTet g sha e it anc n T n t pe ni n e s t md icc a gb n n mi a i pt nl a
cd n
Ornasoecj oeoesg N ,CG i cmt t owEhai lf nieg l v d g r si e a l P aozrcn Nenie n e r r ph l ESE d eosAp t wft prisdi y l cy s on pesnisl dl nnot wr Il nb eohP ast at MGT in m).tcg a eena a i pi us c ,amrst eO e
. oc tjiVi at ao HNA CIC F d s
c e epn 'Ad e s l fi cse i nh psdman o
k r naones v sse dusguer nnt rcwed asr e
ADB d nes nas eneodTl c o recrt si omcrrai a no d pnord T NU TIS a eni ri pi r d uRaoff aca et i eu t re s at uns enP t swvd oc Aomt nee d arP AF enia ,P u mt e az aieoet e Vft aait ,d e R l gtl t s g .ocw ca r c ngc r rh ti s e c s gN a
.O ar prl t scaorp n f .esnfi iA osi T
yaT yi s t noeaC m SF canieonrt enost ti rn ngrv n E i l gccraornp n
t o sinoI adt g .
nnr ea nV uT g o' rid nt ps yt p bi e d v id e i pi aes U n i s ttf og fi ei it oi nenrr m al l d . Iet nms t S
S aesirns h r e d o o i yf sh xaitl csioe m .i pscb e si rl cat sdc raned cad f cstsi eetd ecsaa i n osoei v nbl ewa I
e o d e ii rnnvn ,n cnl rf ee oi a g n sa ajnn
,Al g d g enveooeoea oeuitl israurrps b F, mt ot e O
Y ea nt nll hl n i c ib a i
bi eh g
.irt nmea cn h u i pi i r i r m t mDOt t aat m amy t o eivd ci-vt eeese oad cp t aova" t nen g p e m gl r aeeaso etd we vcre l t p e d si m s e s t e eoerzzozrl rz os ya i ss n c tfa tid gN. i eenreneya t ch a ii n i e e pi sr - br t e eiuuel Wr erbdoth onsms ipe t enn nhm mnipt - o nep s r gl enqt Bcicrn e n gb da ece M
U S
nwsvse" ce i pc i oaiel oenoni pi sgrdr m srdcggrgrt eenurrer u l a aeati i a gdd at r ornnli o T oaaPsc veon nh misl l aerrersr e r o i pi et I t asaah cfdsdds S ph d r e t ref af DwaNoowoFa N
. . L .
e f B a y
t -
- i a y p d s u
l
,au ic l d s n n ieaes .
.q u e wl s t rc n e cet d n gw n e ah en ont usc rt ,a coe eo t o mb smr ii p nnl d ea t
) oaae v d .
een d c ,ictn il ns rmg e t oan uoi u gl re cr o t ss n nat m et ,i c e i iccg f nSs t l iea f oEi uhd n d nl r ecDv rc o naef i ti e C ah . f eNd snh s
( h crsd eeie ocE a r l wt ,n e N nmh t kff e N a u F o t yc croh L iei s B srot e ae t B rm eon s renif l t so gs o I - ehal f ne -
ari pt ia aind 1 o ,b cn 1 nes ensin sd na . ab u 4 nal se i na 4 mmf 0 o one arS 0 un 2 , rob e bE 2 sco htt p rn D c t t rnss eoe t n
'A V no d
n i ooea hihN e e Wpcrh t ttE T at m m e e l . . l a
E e f E
- g R n ie E2 rl s B4 ege M enr Uf f3 ni ug No isdn g ei N8 nacr O - e yreoe B
IS Sb pn c I e V g E i Dd gg Ea enn RP s n Ncie o Ear l ee it f pet c oeni A ris s g e eeny v . mreb . .
r i d ue d d t e l wEd e e c r o Oe ,
vs ir ir e i t s u u r u ef ne q r q rroer uu mu q
e e o e r r C r od eed f eml cupc e e e e n n n eol po o o o h rour N
N T pvsp N b c d e r
W a w ) t A ,A e n o res y ie d V y y e o o
,f acre eier d
e t a ve T n n b l s ii es ,i a sng r .te s tt l t ea n l rg S ru m dPi n m esl r c ccn ig i en N f Ol eN eE i e et pge ea uais bti 0 seo P e inEde cOss t sr ncmne i eoin t t n
nrgr pne s
s ii r sre es Nn a P l
iso a y ee nce n ,al t on I n l fd l e2 a y o y gj c t i r i
C ah g o pou phN sfb no rg e c l o n
,s l d et y e r e o n yh se nrfil s a m p yi A Ictis P r icscer f b e e yd ph pel t mhf it ogamresrg doe L e send f o rht ee t p l o et o s nceet eon E d eti lmne uea t s useit vsrt e id lumil eo V ntdeAp nsoy a i h5 or ee w uih gsnco stt md enanay m I
ret ( y dvet mt fi sl t n iit yan sfl e T s ti e gh s e outga C sah n S on wsun h oobsp i aiort pot .
ihld d o i
s ti c vd E eltft a E vad ol e aep ye nsMomve wss seeaet ev umn oorm R0 ri D ct oiiiss R0 rdaP t nns t wcrin ,h shh emhh innri sel o se ttd(t e r .
O4 C0 diiepo es neo Nue E ol ,E .ep l "snoeiEi e p e d N nsip i li al lg l
,iw ,snrmnhsb m e pn g
c dort , fi sesl p rmsb D oed tt a D
2 oeen s f at hP gu eee d mcad t na nb n icxesV nh Ati e o gt yi eci ns BNY s rrg srs ost ntE ns el rsay aebrf aemi cec oai it s rl mT et n shae AR g paa .ioe aee Di ine mhl orejnn t pe n ii e s t md T O n gNh c s d m5 se t s M ,G i gt n L t k o el e8f r gce
,df el ogu aea cmt t o w gh ai d naeB rr ml er/oae nit e e t rim r eosAp nt wft fSE r GT n ih rop ueti6 w essssnynepsm so eee .
pb d m l cy e s m).e o g s ona HNA CIC i
F rtsrow e mof rw l
o vsqenu wiu0ey uq mb s a y a r gti h nbsh eii g
tNac o i e l vt d nes d . c tcniVl e nep 'Ade s l ADB esrF ee P pesl g L TNU nRi d pi a ril dE i es nsinoBre el os naseneidTi c TI S iCf ea v 8 e oeN shiniabit et mi r y a eni ,li pi r gD .npe ,rA ,vc eth gg id eea owps ehi a pu mt e AF n gsi r 1
seQr ad d Ti nssudh nt c l gtl t si g . ocw
,RD ednt me tdw edl n t sernl eTii en ,h ar prl c scaorp SF , ninavl sr .vepa mu eo e eocn gl bosc i ga c a ni e o s rt il g c c ri o r n p E s a r a xi o aassene tb m
.dt epng ni st ne n i s t df og n el esr cnsii .ec U
S 'A s e p st ledPt nE nolwirs .
eHm,PsEP s a e e ei e y hhjgr ,scnf st a mci eeh n aesirn h redood yf sh fi ei S VNn sen a naea cad f cat eetd I TCi rnco tt em anOE sett on reeg j o tSt o s e o ei d e E geoxc ash e er L
" lbonp hisost ygrn mt ot e ,Ll g dg F f n wi e Tt .rueB rt sire sneo nt nll i nmea O oreot n ed astt h d ati e ea i b a bi eh g o pad g rn t es Tf ae t o pts ihi Y wf r gei ea . sr n o h gd s n i ,d , un Nrt t hl n ic .irt cn e erit s w sP syd e u ,i det ant sNbo Leoa t pedsimsest e R .e Senct enmmLii Be m e e n r e n e ya A ish at ae ngr M vet escd eeE cel ,6 m El gesseeeBrs erbdot h onsms M el ol ei rd icge8 u D wi ji stt ti ni n o ce i pct pi m U rc cvd e eiSl onr/l ososd essesv egof nws vs e sgrd r S yyunnh h uE orie7 o N n s r s n r y y h ii h nmn ioaiel oenoni T gD p p s w 0 v Ek apaapsstdd WE aI S phdret ref af Acb niit b c d e y
t
, - i t d p l e u ,au is n g
s q
r ,d x g t rc syo)n e ri enf sa . os n cetd sa N sd f ssfi ah en smeC ,
a l E) ee rn g aioc a ,
rt t o ,a
~ poc(s ui nt osf nnl d
) oy R dl i ont r oaae d dT csC em rnwce c ct e n eD ca o et ,i n u a wc( oe t sl pn gl re i
n esits
.ei rr pt iiasi n ua g
inat liea ccgm t vdvot s ond n inens g m gi l d nl r o sar e ne i vlin naef C sh eu ib dsiad ah .
- ( e egq r ned u h crsd s c yh ne eo ad nfl ,
nmh eeie t
e N xnt ar et ym iocs u L ea n n nm o t yc s
s B mnce g id ge t e c ei e i til srot e renif I -
s io i
gn ne l sfb ,t s eh al f oena . en i yi amy pt i a o ,b 1 kt rih a r a rcd yy ibscees e gt ensi n 4 oh e n ne sl pd st nal se 0 wgeena ah nl seyr ;Io one rob 2 rul ngr mt oa praw l so p
4, ht t p eopii o t p r o gs m od s e oep t rnss n ah enee evonh u iooea e Pt pedm To n. Rotk t s W pcrh m
le . . . .
E b c d e j
l'
M W Uf N o n i
N9 O -
IB "g S "
I e V g n Ea .
io s
'RP n t o c i a t
c e A i v
e t v c . d e1 d it r e e c r4 r r e o0 i i
r c2 u u
- C r
o st an q
e r
q e
r e
em me e
n e
n al o o SE N N N .
. Q . .
f S a b l n rr .
o i oo . yf
- g n
r d r ff s r6 s eee nt
.d e m
e t r yi ns S rhh an m e t e ss ed N et t o sl a h nl st umn eee ae O h o sc nl ee t s ib as y
ad ag h nn emd I t n e oi rt aa oi nei tii h V ed reeif e nw psh s inI t et ssnnmogb f t f t C ,en u gt t wt i f nc ona A swadd naat c l o . nt oa g ecpDn ehdnieo h
.aunms et neaeco ser) sht eh ctt sl rjo eas E regach nin ,i mti ,ntt niep e , wAoiceewc V
I dub in ,rocinl ue eof cdoe er tiit bt n m. k s t
t V pweh m ir T
C esrspneme cmee gd r npeevt s ighb ,iay l lyoc eox ri sxsT m yem o) . or jt ndt e gecw E oeel ni ow dt s t nea
- t e sl et c cpn gi. li ao rp R0 ptA rl nti soc ncil nn R0 pbit et s easaI eg el gn l ms int i spp
. O4 ogrdd f e enc mn cgsno aoy ccs . st etdam a ,auschnl oei n
C0 lernoe roi d oi e ui enri c ri e r ,
ird eerst g'A n 2 pehl de nnprnct D b tf nnsn aist oor sees td BNY s aenuianea hec do s nen t nsnel s e AR g cceat anc dt reo p aaino c a ei c oi r V gd g T O n i ae nnmia ei l Ndp h gi i e hl rsoIi ea M ,G i l f w',eg l v hWee nu e n gt leg et prt sf sh g is ., re .as ecn d prt sdi y nd ena ionA fSE GT peeeisldl , oi ec rncf o y.dt e l9 NA in atbi eena l wl mng ivm i d ags c t s a n aegn .it mms CIC ADB F
fI die t sd iman o bs amochii t o e gf crt ni nlisdl a
ee ie
,ml re m T NU o nl crt si t ahit sd epsid bl ei o t d r TIS en daiao et sewn eu S osim yso l rd oiahbf sni aa AF bff aca az et aodl c v t sctif yaf ses sht gt ic ttionni
,R casir n en n ag O esesnfi st rc erd oron SF ennntti rn aceedhi iNsen nn ptt o g ri n E t oconr ea weemet jn( n rUepa aandsc pnori U sinpI adt g. , eSh u hl eeeedsif er S i t as h enrr S oi grm e T sg cpedrl eer t e S xarel csioe E r gsi o e n e bi e n r e yi e n Dpnt sft int a mresir ve g et rn I ecbRai nnvn i
,n ens s g .ri ot ,il nici F eng h un ooeoea
.iirirm No eaey l s Eeego nd m o ewadal slil h oh a s a gi yn g
O Et en T
R t
mi s t eoeozzozrl rnaat amy t t o
,depsie ro)b st ht nh mssis ei y m e t p erceensv erri sscarnbre eeio st e M
r t ceiiiniee i nsnn nh m 3
7 n e w mo (m n e 9 geceol tl srl sb ob s ai eea momnat uet nnhe eol a M p eii a a e a ti 1i r t pp yahf u al c ii c t et puv U srgvggrgrt seessn nshh yeo St cro saer c c a g g e s v s s gi e u r n n m ya ye e r S eenirreru D w e d o o w oF a I att src A e e pt B npee(sh srrp y N ?
Q
. t . .
f i S a b l
i b
- - i ,
a s m ,
ic n d - es o ewt m r n n p nose e u e s gnyt h .
mgwe er R
e rikss os y tt c cotd ont h f s5es anen coet n a1 h ra a mbo g g tt t ,
ea nt o r n ,l d
) v dd is i rnwop ohf o ol ae d il nn e cact .
e t oaa D o p ci n d u cr t sl s u gi r e e n et ,s m ii at s innt acgc mt i f nSt e n uc t f oE c t ondeg l h eae n ecd e s m gi p n d cl rf o j y ivsi neeff C f eN o S dsiac am a
( ocE r ned a h rs
.- s a p - adnl rein e N kff i l f r neh e u L croe . . ym ae oht ye s
s B ae h n a
n a
t ec t st ot b lt st itif n roni 1 - ne a 2. a i l yi sf oI enal s pa aIhd . a 4a i a 1 cns a 0a ibsceg e , si
,b h sd nan a 2a el n 4 ina o a a sl pbi ntl sy 0 arSi a ta nl sad oront e a na oa eu
- 2 bEs oroi rn Di a ea p r a gl h pt pl t eoe v a ma s e d c t pnsa n
e hl hNi a a leaa evoen iuoeu Wscrq TttEd R otli l
E m
e f
a Ea a
a a
e N
y S a b
M f' Uo N
0 N1 O -
I B S
I e V g .
_ Ea RP s n
io t
c
'A e
. v ' .
i d t e c r
- e i r u r q o
) ) e )
C i.
1 r 1 4 4 e 4 0 0 n 0 2 2 o 2 N
e e e
. N e N e N N e F S S Q .
B S B ( E (
S a W (
L
,p e b r n e
- iaie o b iy h e pc f i b t v r n e s d
- S o eea ps en nd e N r t mi i g ho- ue b 0 p or pn t peor
- 1 T
p a
irsa c v ft i
t eo svf e ena y
- C t on rrbsti a s A d ean u o aan
- E n
a l hi bt no om pe pre h uys ll t V a d uehmolf
- I l ictnl e itd swt avaa e ir T
.o al
.C r l el t e osft scc
- E t pma ni tt o ne .
R0 f .tn put ef f nopes
- R0 aso acs m e a y oi s h n O4 rnc on ue crnit et o C0 co hdI cr oe ncat s e
i
-- ;D 2 ?
rst i o t' isd dn ae ,et d e n u gl ri BNY s oi wt n w ihil gued
- AR g f cs ra e vt aufh n T O n et yo t s e dvspwo yee N ,G edn l pd ae l c id uc .
SE pee EGT ret
- d - e obb n
- m. qne n ieohnl il mrt HNA i vae o a eat srh aa
- CIC F ocrs cec dt a dnctt yl u
_ ADu riie pnug snr ci . . asu n TNU nnq ui oe s ' ,peu r pt c TIS h qn eab . iI e osdnnvea AF t cea rl as d 'Ii oi h
,R oerh ulf e fda csi ntf c r onn O nt di meette
_SF E oein
.n eenu cved e ai adli e
atf: o cdhf oe oree cse U dk ag tt adt o l S ati rubc ni r ese 'nhq aua sb S smns ps o eeaa I e oe Advp er dyw ot encreg rocd il i dI nard F ut V na vas t na e ael
- O d sd T ahe ent aon .is el en s ane uii rtdw Y ) ) cera ht se l t sef eo )
. R 1 1 onu gi t h s -rum it aaegpat n 1 m 4 4 rndn poeg ouo udrt eor vchnxrsk eiti ece e
N 0 0 sci h a ph rpt l d gt 4
0 L 2 2 Aros t pt eps eprnsens 2
? S -
e e V ere T ppd l Aui AQsw h un T sI h a oithoo Tl ffit cm e N e N e 4 '
N e S S 4 . 8 S K K a W
( ( 5 (
y t
i .
l )
i s b r i eg s
n f n o
p l oa a h T s
e cno ,
R ini ht g n- ce .
_ ig ere
_ t c(
s s e yi l D nd e
.' s e N N a
men h o n
u r e e ot s
_ s s
g K a m a n
o r t oe I '- -
- 3. o
- 4s s t p 2 2
- 0a est
,
- 2n vnf 4
0
)
1 4
0
)
1 a
- a aoa ei r
)
1 4 2 2 a tne. l isc 4
't 4 n ee 4
. t n
0 n
0 e
e ca Ace 0 2 2 V eh 2 e e a le a. Tdt m ee m ee e e
eEa n N N
e e
l S l S a a. U . 8 S E ( E ( e e S a W (
- Mf Uo N 1 1
- N1
" O -
I8
+
S
, I e V g Ea RP - s 1 n i
o t
. c A
e v . .
y i t
d e d e
c r r e i r
r u
q iu q o e e C r r e e n -
n o o N N
~
N .
N F L .
B a. B a
'yr e en e en e lbio s . r . l o r o- e 3 y e - 3 bi e
~ t sh b it h it h
.sa sa e0 y w at t e0 w
.5 l r p2 d enu -
p2 enu y O
N k
e' o
uom gpo ip 2 et sn h ol t pa rt enl k e
o i2 p
h ol t pa rt enl
,I a t epr t ue s v vaa a .t t sv vaa T
C m.g .
ruf s
f r oop am ce t ee rr l u n pt m .g .
f r oop t ee rr npt l u
_ A owns 'e e l o ere c owns o ere c t ei e l ec ne eE peh ot ea t eie ne pehot ea
-~ E' V l ven i rg b pn aia oR g aM prt ue f h otf l ven irg oR prt ue fh
,t sw,t otf I eeea ' c pi itt mF sw npef u o eeea itt u o
~
T nrnh i r an a8 nrnh an npef C n i c l ea t e d osonroe n i c t e osonroe E
R0 ogg snnn pmv po nm ee ti n ttii a ft . sb l ogg snnn nm ee ttii a l f t sb
- R0 ri e g asn ml r eait saa rieg ml eait saa O4 er i i uE od crd at ee er i uE crd at ee C0 pers ht c pe ncdhf rg pers c ncdhf rg
_ 2 eoe t ad oN ps e at aad eoe oN e at aad
. D gNY s
t nfd ih e dF us d e r e t nfd dL d e r e
~ fi wtl U se ih necdl fi B ihnecdl y ARO g
n agsd l e r vtI c ew agsd e vtI c ew g rnt n yt a t n ed e y . net o rnt n t n e net o
. ,G cenae l nt ai pd eh sn , cena ob y.itehsn ai gSF id pes u ia ob .it ek e- u ek
,GT yNA .i n wt ms ouen m oui mn qd ee p
s n sr seeynt g wt ms ouen qd ee n sr s e e yn t g -
cIC F l org cc dr f a nl pb o s l org d r d n i pb o s 3D8 7NU l hii od ae o s ocx co l nii ae nocx co at us nv nv en m sdn eed at us ui a e d gIS iqe e a I o ed isu qe I o osu en m gF R
t wed o r rs utd f
.c ca no fi qsrie cet e h t
o r iwed f
.c fi qsrie cet e h
,O ns e dre os el m e di e yt ns e os m e di e yt SF nnv eot a idr ada tl nnv a ada tl E ooio cpa e e e nnnl e o oi o e e nnnl e U diar oec cs vv ttii uab diar cs ttii uab
' S S
^ st p rri p
nt es eo a li st p ni a li si n p r nh ndocy si n p es nhndocy I ecoa Qb idy od . ot gnvea ecoa d y iotignvea f
rec ud d AAa VCf . va l se7 i l t t nsoss iu pm. rec ud d l l ra t nsoss u pm.
f d sn T s en aa1 aoef ness d sn ena aoef ness el ea car
,ne a p2 uid o ,t n el ea uid o' tn Y h aer s - si2 l t aayatl aI si f o car s l t si ,f o t
u ocul gl eu it ic ocul it aayatl ai rido urbd r it vcnhsurt rido r vcnhsurt M pner oe e eo et r ei a mgpef ci pner eo el a ef ci P hct hi ec rp ep eap rno l d h ct rp i mgp d U Acon tl vo e p r a gl en Acon ep e p r a gl en S V ero l rar hu hne h m o e u eh o V ero h u h moeueho TtP c Achp T s T uR TI ft sht c ItPc T s Tift sht c N N F .
L .-
B a !' B a l
se nn
. . ion o
.) ss s i r r ce e
g ep
. d
. l f n t l oa l f
- a cn io ,
h aa cr ic ni . n 4 -
ht g ce .
ere t c(
s h e t
ch et f
yi l yo nde n n
a an men
,': .s mo e N ho N i
.u F ot s L ot) s 0 o r B oes s t oe t rr I -- t p - ce
~ f'yb' 3
4 s
est vnf aoa 3
4 ssg ei n vda a h 0 ei r 0 lee
_. 2 t
l sc Ace i
2 t A h .
t g n
e m
e V eh Tdt n
e m
e V oe It(
- r
=
l E a l
E a
R2
_ t4 6
Mf Uo
_ M 2
N1 O -
- IB
_ S
_ I e V g Ea s
RP n
o it c
A e
- v . .
i d d t e e c r r e
iu i
r u r q q o e e C r r e e n n o o N N N
Q .
S a b e e t n d c e d rn er n in e d n ed e h a eo o u t e ce s et h d hi ivo p ia di s n t s S
isenrd t aenh e r e , e Non wt t e t r
e r
nt ns .e aa N
D t andut ct eio h r wooo v S Qt a es at cr suae el h rt e
p a
acoI) u - 1 e m icw est sf g ,re srnn1 l dd rtb I
T f nn n d r a t ed cat rn nv oe t d
n et oo csiil E
Ine t C
A fliosi el act s ieeecd sh o ad c t aescm t e h a a nnttAh eoacL a ti s
E n am es f nne pa serdl t e rcmuM y rl et e iI et d nh oee nlt e rr( o o V i)db r t d a ese I t pu sae u I
T n n
- 2. a t nd od n 'e i t ervs h yt t ap n ,rsh ese crl eep f rot eef s1 q p0 e5 C e3 si a d ee we id it pnm rh nn1 e ti o S R 7, E e- , ut i w s et . 5 eo do C n y3 R0 bP smar en inlacc di nrhs - gc ens on c R0 E n uo nsvo a nf eot s G t aneii ne D4 e N o sl f esii ,t ai m ie ry a i ht eh C0 v ida eest t oy t e ,wc eol dhat cl ut D
2 adt rve b caa . anr snl e neec) r o hft ttt ul q BNY s h naaet a
ovrN h t asp t n uinhra ef AR g t ard eneu erreQ vpedS tds i u rd ei' l D t e owot t t ro f ai ci s e F T
N ,GO in a ,pah q h6otT e a
h n pi sr ddd n n c
nei t pI n A o oh c ti ft oc3 wnd I en t
ESE d t0 s d gd no usI or nCi w f i4s n se MGT n - , a sinof oe ceni(t edf sl t si am HNA i sP gd . e si c f sd wi c nu ef ccn B u CIC ADB F eE nnse rOiasr cef nd ne d
oea sn g nsdrt esa ivus eo cneiod nopli e ao c
I NU u ,t ea a t gt sc eeene rf e acSft s td TIS d ssc t e oi c l os irl gwev r t - nis a RF e5 eeos sh nse arn ecd mi ssa srGod e DQ R po no Sf
,0 c o 2. t d r eu opr i nt ddg el e
m i eaesut nul ecc qwsoe
'mtn y I n; cd r Ad QC A
r4 , c fi ant i aae idt d A E
U p n nd icod hen ega geosdr el h l mnad a CN S
Podge til nd ne r t pt a uh n Q gE i ni c f smt r su eak cgo S
I y c
nt iSc rE u sd ps aso.
er it a ccet eet ad o neg iode r gi n
nconc ari pk e nrs ioan eo raot as e
v ,f ss eest nt1 i
h eS .
t ee nt d
7 a eDrt t pp h e t g i gr ch tli scaroc f oa G u e t neen ssnt r ane . sneeat act n w oi e 0 o yel q ao o uil s ea Y e inn E nmt seh em se h ien l rbd sih vr erti tt luua nce . rtt pab2 pt j2 wl r R d g( oe h e gntt g aear reit r a it asnucu A
M a n crgti r uiaai veca d eecna vAf a nesist ien oc n e3 n oauc enid d n eot eVi u eI m f r v e M
U I
A/aqraq 7t iuit u htli n il n egpa aimris T cq r u ei s o et p S
t rad e gart e ee e e c pd i p ra5
- V9heuh e l evne h npt nneoco h opd h noioh e h -
T0t rdt r AceI b T eas I et cat Tt s a T o d pM T R AtG s N -
s Q . .
e S a b n
e t
le p -
m d o a , -
C n t t
yo r. c n
i ,I e
e let e p t ccs S m
u aune n c
urac qt ni ne ot o eset if ,
D d nt c t oe aona c t n
g ncir uee I ap rrl i
s ) r sm y t ap s m e Se ,r . n) o D Ed nt s osc Dioss Ccn
' s - siue eI )
e Nntdc l p 7 u . E oano asd 8 s ( crI r r- n s e p /
I 4. gd pl eGa 5
. n( 1 4
0 innoan a ,rg e Gst e /
0
. 2 r esgns ei na 1 t eenee Aou (
Vi q
- a. e
. m
- n. nsi gd ist Tt e ad i
5 gesde eca 1
.. le .. nrenh Edt at hi n TfI 0 E.. N 9 9
Q .
. 1
. . S a b 2
Hf Uo N
_ 3
' N1 0 -
1 5 5
1 e V g Ea RP s n
i o
t c
A e
v .
i d d d t e e e c r r r e i i
r u iu u r q q q o e e e C r r r e e e n n n o o o N N N c d e d ) t o e e d 4 n f t c e t td0 r e t o e n d ce en l eN e m rd dr a e S
ov - h -
e oee nne t o e nl o bl 6 t ) el t pt c siah pt .n N gf o8 o t. rEn esr Aa w e s O ienrd v8 e e Ri u V ws) cd t g I srieen - n 5 wmm l o T e1 s cn nn T e gxi5l au y s t r t au ei C
A dr ni o ,ame- cd 8 ai ,nrr A o gt cs nt e ncu9c o mk eed i df ea E
N sh cM oe
.i os enh ejePl n rm Qet f nI l t t rn uet wocEf as V Sd neoa( i paPi qm t roN n a iur I uep t rc pt eue epr o sw qo T
C el mi e s n o rcepsnrf s A nl h rcr b psc g ef enr
( eat F oe e a nt r E uie e mii d w sh e h i c e R0 hi l cd c 4 ucw e C40 wt qrh iuaernen eoma 1 re 6t ps sQs aA g tt hh c ic n t cu us wednc ajega rodil C0 2sSm D
2 soeeth crt enrv t os n e BC in li ss f a(t dresp pee s
c ed oef n tI nl a0 w . neh c nge BNY AR g nd nseneri aig vAye r
oreo rb t5 am re ot se ndnI Da 7, d t T n ops pocr caAt r h nr N ,O G
tdidl s seo r ef np 3 i e lV cr Ti o ist e eo n.
SE id .lpse ms .l h EGT t
i NA n
nd et v i ndt nsmah a
R sCd o
n Q
Aeat t
og f c d ginwye re CIC i
F d dm iI newt o o .
hl ti eu Chhl tt u snrno eob ieot nedt ADB '
nenoeies s l aeo 6 a ewvc it aae TNU ut a cthiet at yf 8fdf rae y raml v TIS oa snct srr eeo / oe - arwh g el ua AF f usgae yao wdl ops '1 tt d oco . e e gh
- R ql nt nfl p n 0t aa e Hul) ndre
.O m eii s n o a e e ogml /uc rr so1 ieard SF adawno nrr n s nE a 2oie eo d gg n E eat aicnae ni 1 dh hd .yo6 nnsoa U t ner o ht otAN 7 nt t nefh - eaet S iddrmicT n CnVQ e5I euitP h g ,
S n eati e / uTS h r ta vrt eE t cnde oeyeh ea m -
I i rrhtbgsm.e t o-rm 1 tt) o at hd t nmN e (
a h eh oa anr F t eat o iisl e 0 fhnm t nede t rCp O aws u s ,Aessn ndt et e bt e5 . ot ee abiht a ss Y see l at0s cl e tis e ee R lagcc de voma eh ih a8g n
wdrb usoo ua .rr .
Gt u qti ieeeo s gt t ex sie us M e i n a 's.l vnen w Iennuy ro .d ert va l pr sn p ii d ei d e sruod e i ert eg M
t w
eal sl deasq td tt u ond on suapu e ee15.h rv e wncvy eauaoe ei tt cn S h rl nenhh ne l oneo d oa h rol rh h renrh TdaiwattI S AfiRm Ar(t Tdf ppt T cb aP c c d e ly l t s
l n A e e r
e e a. V w u se T . q a ul s d
) tt ab ng e!
- rt e .
d n l on co en pe f c e e l ne r ei ol e u t a s d p ww l b ej n f yt oern t a eidro i oeed roay er vt ner t hd p t bd ecawp n st , e ,si .
du o g l) rsel n sr rsae C t ci o
( int aclal rnnbi t o tt gi h
' s e N whiaoeeit at nt mrt a ledn os nrt nnie u r i e owt n Q heeeecl f v scaii s S dncddrf ul n a rr s ie uirra od wedce I - g tdl uett cn ne l c qt ss b t a n ,ea 4 it eenennn e goecl ra mwI rI oi rs i t rn 4 euo c g ag 0
2 eqs ne .sne ygt rn ai aei ei rw n
s ehft e d geps oad t
n igac d k e. w s e h nnail ert u r ea Aoecv urei h r V nh ce e EI l( ad cod Td T et ar m -
e l . . .
. E c d e
Mf Uo N
4 N1 O -
IB S
I e V g Ea RP s n
i o
t
- c A
e v
i d d t e e c r r e i r u q
iu r
q o e e C r r
. e e n n o o ;
N N -
N B . .
W a b e .
e n c e d r e l n n e a a isenrde ed ce -s et r
h h
m o
r y
l e Non db e ah .i rt sa eitt e m dR nE a
S t aenh e , e f tl Bt as nwnr r a) e N t andut hr v- h cb W a e ee a rRt s O ct eio wooosst ea esh . ggmp gE ne
,re nu est sf g r t b 'r r w i o ti rt d o( eh I .
T f nn n dr a t edAn eoct n r mT C fli omi leeecdB ao d n sh oV o rl oa a Psu A el acas ss ad cTi aadh t r n am aes".
pa e es fnne met t nnt E et e iI et sners d ,t c ydd l t mnn V i)db r t .datil ao . eseda eensae l n
I n 2. a t od nd neitt ab - M . s h yt e t a pi e hsacrl ~
T u eep P eI o
, T ervsat os spnm dee W s r repse ' .ie r",ic C e3 wef v ti t E e- ,siaut iw nl cii enSeo nu R0 bPsmar ent c usc i actt .bo- gc e q1 e uo n s v o A ~ ,f aen anc R0 En s iG me0 p O4 eNoslf ocl e ,t ee t ot r y' eR0s C0 2
v adt rve ida esii - n eest bcaa .ost ac ci t o yd r anrir nt aeol e chft v
o gB I s
- n .
D s
hnaaet ovrNigoui h t .o mdit n rnE c BNY ard a erreBt n o qf td sec uef t e pi E d e AR g n
t eneu vpedW eiree a
iur cdif ai mr- np T O a ,pah q pi l t dd dddey oncohc .I eN aS N;G i h6 otT e hn srpsea n nwl dee ti eB -
E5E d t0 s d gd n o mi s n p usI e t pw f nnWnG W GT l NA i n
s P gd
.a sinof ol oI u esic c h .t oe sm fsdni ensedf nI inu oi-gR i e o
_ Cl C A09 F eEnnse r Oi a s r cef nd netd d ewsrsa oeai snot l
o cvus ei e o itaE nEth at TNU u ,t ea a t gt ci s e t sc td arf rf e ic eal e sl TI S d ssc t e oi c e v c c S l osae - ai r AF e5 eeos s h n s e j oi o arnid d cssa ft ac
,R c2 re nt el ort rd povi a c p'm n y' nhe t i eht a SF O o.td r4 ,c opr u
I fi ddgrpspn ep i a m i ev antdo ti saae cl csl epunp E p n nd coden ern ega r sh - el h pmsI e U Pod ge i h fsegy til np wet pt So r S gEi nic f smt roatit sue t t c ,e S n taso it a ol b c si n e gh d osinrs N sns nnsoan I
- iSc er . ccet ael odeWn a
Benin rEusdps eet ad eardi i r o ieo WroLo F eDrt t pp h evt a b t g ei e t li oi i a n e ". e O e t neen ssnt reah oi rtt act .t mttt nNsehse ao oldctt uil sv aaauua . n ana Y iEnmt g( oe em h i en c l rbdi cil nce escec R h e gntt gt Q c d u aears sira it c ei mi m n r ui a ai n Ai e r vecan cf pvAf a edf uf
- 9 e3 c r gtiu 7t uit in oauc htli nr eC rtt eas enido il np eioeVi u pcr T cq r ii r i vct c t A/aqraq t raderenl n egpas Sepe
- p ph o pd ee eoese hrpnp S V9heuh e l evneuh eeo h n pt e
. T0t rdt r Aceibct 9rc T easr GsaTt sa T psi s N :
B . .
W a b d
- a .
n t y o .i n c li e p
et e t ccs S aune n urac qt ni ne -
. ot eset if .
dnt c t oe aona c t ncir ap uee I rrl sm y -
t ap s m
)r,rh Se Ednt Di oss n) o osc Ccn s
~- si u e eI e N Nntdc l p u B Eoano asd s W ( crI r r- n s e p eGa I a gd pl n(
innoan ' e e a ,rg 4 Gst na r ei 4 esgns Aou 0 eenee Vi q
- 2 in stsi gd Tt e ad t gesde eca n nrenh hi n e Edt at Tfi m
e l . .
E a b
Mf
, U o N
, 5 N1 0 -
1 8 5
l e t g Ea RP s
. _ n i
o t
c A
e v .
d it e c r e i r u r q o e C r e
n o
N c
e , .
h s .
e , ,
e e t
,tn n o g3 d p s e t g t t n0 e i a , rn on ese i l a .r - p S B s eo t edh cm s i eh3s rn N
O a Q
A wi t det s etee pr e d e g n
u b eb l c4 s
- e
'e b ce ue rg an I t C nc erofSi r i
- sanPc cb Bi T a eu t pno- u e r w
.A C
'0 D 19 -
t r t
ae rey e Gq w th e a r
sat oE o abui bt ep r
t o .
o nee t 's dr t a 0Q 1 sys le rn ,r sat de eaiar nv y t g E 6A il n rreaa Rho r ht rruR aa ae V
y C
,h no ow iA Ct ge t at udC cht Wr I
T lS st oc g
e resoe nrQcN dn d
si nw t dt geF o C eE . nd ,e ed e t ,i meea ars cQ ai c f oe st n ea O ,
P5 E tD iesr wuidissvt et eAenrh ih e M -
R0 a wi t e l c n r eii o R der l CroPt ct v 4 R0 mN af rw ) cnaCd ef nA eno f ec . n a I
U4 iE ri o sna os S iip . eew gsg esh nC C0 x dt py Ri psnc ygF f ge1 rh l nen ie iC
- D 2 , oe net C egg dl n inr8 t saibi ci ,
s rh eeri N s r ni e n ni e t e 9 o eurir ic0 d g BNY g pt td r ycisl aodh n Q1 tf st ere f n8 en AR p ai Q o yasweb nt eoA oacece ee9 .
T O n u ti C ,G i ani qeCa Aj l wiaD a ,,i tl dr cs1F n dtCr i e d
ew cansn iei di1 e c s id cn E3E HNA GT i d
n d es wt ev
.da9 ah1 e m sa o e d
.mt s n s pi1P w
- l it8 n9Oe e
eusf eet u e n e gd g siern n ei o a sftB oF i
ClC F er n ,1 h ( o e gt po Nt rdea e svvoE ,E ee s h ieef s hdra l . .
A09 TNU ivp o I t nhinapeI e wdtd rsertd t ot a) .
- se s T se r e e e TIS AF ee rr
.nthd t o em ,teo ,b stf u rat basn Bea f nrD yi a e8t 5 y ort n o a rd o -.dussf cn ers et t aos a sd u oap r/i
,R O mQ epf: pssgoo rl s aesqn m Q e6l Boi oetI s . eut eo e sA w(i SF E
aA eC ueo1 sr 8 egt ndiR mx re p e-r so 's Rdl stRi t eeC b U - s t9 rnni tA Ci sa t asn sti S
t d~ it u1 i ernaS .e QwmegcFshs ryMR t C Fl tt Wec aa- g gu ruoe a h ert S ne iD i oc I ot ed e A a e eii Crrnsf ' ,ori nt e Qi
.N t v a
nr ecet cpu Al t n .at ceh ner F
O i a tl ae h
ta u'.yf o r e
nt diiel si u c qn u gd e n t F n eoa e .
Cisn b eo oiii h saidhs tihel Cn o
nbt o e
rdyn t i eRt s
tbe Y l ur ggce nnnb oa e e g pi h r c
nSti .tst s wt ct t cnc en idC rel i icnn oo e uodtfl uil fi c ut a gN vnB iiddid t yt ni newnli ese af ni n - ueu yrir sieo en cf ad et ruce . stl neie eii e d ar H
P eiW w ali us negeogust nm euiwl i cst ou tt ct esis ii a dest hFe w
rt cr nee rl g ue U ear gcf sR vs stl sl aicc nnf n envR ,t eapt uan S h ro enesC eseeoeal rno ioeo hoeCnOe h usn ova Tdf RidiN SI dbfDccwid Ncdc T crFiRb T qee FEh c
i n
s t
l su e
r ems see a ul r r
) tt ab d n l on cos .
e u e - a n
t f yt oern l ne s dph e rid Tt i oeedroay- a t hd p t
- n st ,e ,si .re o g l) rsel nn
- C nt al t ci o e
( i acl rnnbi g
- s whiaoeeit e M at nt mrt ag u B r heeeecl n s W dncddrf uli s ie ui r r a e I g tdl uettb ne l cqt ss 4 it eenennns ramwirI oIR 4 euo c C 0
2 eqs ne idk
.sne ygt rn
- e. a i a e gF i y t gac wseh rn n nnail ert ua e EIl( adcodm m -
e -
l .
.' E c
(
Nf. t Q Qo 6 sD eI N1 r O - uf IB d o S e I e cs V g Ea ot r
~RP' s
. rna 2 pee n 0 ml i
o 6 cec t 8 i ru c fi N A
I iu R c qf 1 E N
eeo pr v . . ,
E s e i d d d G - ec t e e e ehi c r r r R e
r i
u i
u i
u C ittf f r q q q S stO o e e e n C r e ped r r l
v ome et e e e o lel a n n n s v pl o o o e eme N N N R DI r d e f g h m a t f sr o t r e n - o tf ia dB t
a e
r end rI n esn v wo As
. n e I se em ef r mooed r u gl .e a a aoi Vt e Ral u dcn S mod as n w s nl t T n ebo Ebb nna N sapo t id se , l a e r N N o c o 6. e e re e
.to acoseusm 0 t eei gt ege es oEar d2 vdw l
ict rre na e gf rngnr wa .tGt ap e i
c nQp iW r
_enoegnaa nclCi r e y h d nf ivi A
l f oA ee ina h wt hi ah sh cs . optT es I rt sNRd e nooev niCr em gce ec es sn t srBC h ai e a dsc il aWSQt tl or E ot noen itd ore ac i l he-V I
cane uey ig sb eevareh gr
,t ug dn csexi0 et h ef1 d i I yt b
.A
.ar C ev l con aer e T nl e - nt ot art negea pnT uSt sh C
i6 e ig .l eel n nat .
E oat 8 vx eat a h
ivnch h a A d r ei o c s e m
ecWt asvh o a ow s R0 eein eewdr ne7 n leert et se m . c t n R0 u Sa nthti a g r meonPd R u .ip4 u o sesw A eno E rE ms u vi o o r rV rrei O4 C0 se sh euee . rnHo guout eii p e t Nr rsDeeo nm d nnse exHt no oT oems
.re d fh ei BNY D
2 s
it e
ev
,s o nsnsiuf g idi sesrrnn ict oEart n
.sese .de en pI yeT bd th nl wl y ai yl ormd p re .it nt eas v
tl v t , mr pe AR g hsa u l c i n ,d oa mnri T
N ,O G
n t gB s n
l el eee nrdeg t edo .h c itlf dlueel i re t eee d SE i
fi ae t ch eh cbsieemn g at et sso l tAebeh al mvd n EGT HNA d
n owtl aai i
nt wt n aonsif rk tl ei h ni t uf nne t l asV cot u
qe T ornl hb eel a t orwu CIC i
F yrDf ,deeep d ,tti eriia wgct um oioerr d m ci m a e rnp rpel rioos d puHwl ADB n st predan sq n et e h rai sd iw n q a TNU itd Qo t aoocnraeuer uyparet o T
AM S d rAc i oC ril m c u d h c f.ro ot erao cn f fl ol szi uo h nin odt oh a , oer ude
.tan u pnv e i us pniit d sh a
,R l d h fN adn annqsh awt d e f iz stt m SF O anS c vee u eaehd rtdt nsWnpaic Utt nge mcoaeit a oi g r i f
oNmt cun at et mnen a gneNr E
U e vDs Qbt u s raa w0ucdel ee sa t
el t r sw B enes e eoimBo S aoni sWl ers m t cf uWd hdNd AuoFs 5 qced p ,c ih g t b mrie eec n S t nE Csn ead n1 ogat n I a le .
eee .incyr gt ern o nt oeo earl cnp o l nrdot e d av e ef6 elfdeoi i0 o0 lint rnl m pp em i aM nAhi8 nvrd wje nn y , t - tl eia ud
& Vtt9 n1 inh aeeaotda wt rran nrn aB cl c uE aa d ,
cedinb md ei a n t
asQnro Ad ef Y
R imT enedo d e -
y ,su cdpmaseoe i ght e lE xt nes a - esosg ot e d uzc s e l uiNau dl t ewI t biisah al Asea M eee tt nrnext nwab n r gt gh oni l vN eB rI d ei n sn rinf orgi e sh w voVl cv erT aoo Mr d wie8 e oi si t reweue Wi erw dt ocr2 , t urr U t vv1 vpsns pcadgv e- eesd a nsced0d enenpp S oeea9 eeeoenperaea hRhh ad r ei e pd 6 n h oh a p Tbrh1 Srd cdiardmrh TEttb ad T ct maa V.d r s a 8 a d e f g h d
t e e y 1 n r p 0t a a-l 3 o l , a o t n . p . rye l ; n C s goer A ee e I t g e . h V vl u T un hd eet a T . eb q t e ,
) ng s di t
e .
rt
.biw yct t y .
(l l t n sd a siui d en t c f c t er b ui t vb e ei ou e nl d rl nx u ww nr ej el dt a eo ,t n n t a er dsner tdro man ut g esu vnq m n ga it n
bd nnawp rsi o uKinl c p o sr ao csae t ns sI e iecr c - o oor dt ee C t o r gi h n d eso eh
( oenrt rap
" s icd n obi e I e re rt nt oni e N l e p wt n deh srf d e gt u B f v oaiI ewt goo nsna s W n st rr t nf e E .
s od i dce n ,n e ve cna d e I -
ng ,ea h t u8 o o2 iwSr aEa f agvi raem 4 e guecl m3d rD o oit rs i orn e d s ) oe 4 ag snoad 0 n eeft e yCi N g ssnce 2 ei d eps llf lii rEn el ael o i t at rb t
rw ea l rei r
a c dmw a ut a n Al ecv cd e noa d nat n h r V eh ce onp err pahoo e Td T wt ar L as Vfd m U mCns e
l . . . . .
E d e f g h
Mf eve l ama s Uo v f l t t su N - i gf 1 t na i sesl s t e aat N1 ci e .uti O - eyrb ew "e h "d nss '
I B S
I e rf o iidtsl ssT l l U a
leam "y de V g n mi ul .lorl t Ea .
deewnawrenc RP s ndt anethOe
. ' n aissmoint f o ym i ec voOnf i s n s e gt oa )
t ea t nir"
.i 1
c ll ysid tl 0 A icptessoMI yt nEnwalema N e l nf i r B i
v ooadt pi s e En " CD' d vof P eef os
.If d
d t t t rE crn n4 e e c )cra eB a I eo0 ir r e Paol .di f lP" ci i r N f edn pE nt4 u u r Oc reuo Bnea0 q q o (i s - p t ei firz2 e e 4 C fl yod b dri r r riatl er reunD ecueecol eccaT e e wenf vailt a n gA n n opaael rifl orc o o Psmsdppwapco( N N N
F .
1 B a n
f o oi 2 y y e . ,
s t e r a h ) yt s e ec dt o m t Cl u e
'S o su ui t Dt p u N
d urt l n a s n E nne gs cu l r i U ei c ns O n es e u o (d n i i I
io h n rr g t e nCa r T t o po e cf c C
A t
cd t c
t f r aon a neDn o pE e .ee ec f eDtC nn un an o e gn itd nDi a E
V ra hi n "d h gne cnfiE gn t t n t init uioaOne I ss d oa sn r m et T nr ee dh h wsi tdt o n C oe tt ee t oea sel dtfi E
R0 ce n
al i w
l rm nt un oa
'ri icu ct l d oasak m C40 C0 og d e .
s ai lpo s y odd f an a
Cre ergacd ct f n dp nb a n D
2 1 s
e InrN B p l
p ee noai pa BNY s gr t fi inp n ht , a td m .
AR g l o o o t an esaei ,t n no ent c uo nvarf gs f
N O
,G if n a w" t qi iga e mni SE id w ns od s aet hd pt ril oas ne EGT i HNA CIC F n
ag rn di s
sht r
eso s srs t an k .
d e
r u
hd a t ar di p ne s
e)c DP a eooet Uf gsgti
,nt- sy et ADS TNU d u nf pgc n
nmo e c
n ue o g(
n nan ,ro TIS AF an h o .
~
Aid V we e
mst et a i or oh ,
ft g irehsrat siwo
,l orni
,R O e cs r
T as ra irnt p n ew edeip SF i o moi eoPt eht E
t ee hde urn qp g at t inPO nt aC i rk t r n e s U sor idc e e gf t h a ei ,rD S
S omo p w wnn ai rIl b
ire td e nt et :
s noat gypD h
eE E l o I pk sh yt a e ou ,s et set n orn w r rit n . ib ne f c acnno F
O oo eeo oni ia ti oc oi s neo f wi it t uu gi ario f ml eu w Y
o t vis a s nr ut t r ef eli qno R
ec rsy l g eet ncp col e r e gl M
ek u sa r eoa t pl unh git Ai laou vcrn ifdo b wesi pnss umt s npe esi V r e t g f nrsxoea M
t et n I od Ruw T c ev ns esi OaP aeCd w S
h oo h aoe T nc o o o Th cd o N
F .
i B a s
ed -
k n d "d a a a ,
nm s a yo n
n hh r li ,i ce et e ei e t ccs
)
it h n s
wi g aune vrac qt ni d o ,n eset e p2 e dnt c u p aona n ot r i
" io Incir ap t
n du nf .
s ) r sm y o e gr Se , r .
C k rne Ed nt s
( roik
- s Di oss af sr siue e N m uo N Nntdc u B df w F E oano s f sen s
i B (crI r t son e p I -
i nuco i
- gd pl <
4 5 Ifj . rget pnrc ,' 5 .
4 innoan a rg 4 iou ,- r , ei 4 esgns 0
2 I
emrt b
0 eenee 2 in sts i gd t
t k s iern t gesde n nroo n nr enh e Uawc e Edt at m m e e l
. l .
E I E a
E4 B
Mf t o M
8 N1 O -
IB .
S I e V g Ea !I '
RP s n
i o
t c
A e
v .
i t d c e e ir r u r q o e C r e
n o
N b
e N , , ,d dd es o e F ye gd e se l lea haav u t , r geu Brr au Q neh mm l t a di hc snhd it t et a n n n npm ost P ra ht o rg s e i S amadd eit e rt c t su ef N yel nt sf en c t lo N c orl n usnon I r e eii y n no ess s t O y i ,cgua deiro l c aee h t nr Ws o el ga pai i gg t I l sry oo et P t nh si - d ugye c S s nn s d - ,n mii n T
C t aet t rwe nh niop c c
e ,dete .d nnt eu gw
.ti d nt s .trh ed nGt o arl a A e el n t r rnsau6 m nn ineeusoc rea ac rel r u n gi Qi u poshs8 idiit f
e a ei ph e pi az 4h geo t E qo b sA o i et s/ rn en s l h ssruw yl n i s2td n
onr V ei e a a C , s gt r i1 t anb e ,e at not s eiofd a ritRa I rt rrw n ncd3 0 e o PgnE T f cue eoe t yu r ohs s hti on no n C ut pehih iud 7 s/ dsisst s et nt ude T ut ue nEceo E
rra/a7 ytiii s na d ec awot a s f ruosttt et 9 w0 t aa sli eh rhnti ecef a R0 otf a c ese0 ol r) ni gt oti at .bii u l eaes R0 s ,bf uo nnb 6n neeP ob y fi i c s f v) q Pt hc O4 snf y I rt io l0o ddC cat ed wyca ehT e C0 i oot a gcdi - e t oieN e tl t p t iC ri h nd ror nt crFd BNY D
2 s l sc i t y nl a .no Noidsoi sn n eh lune couOu tPd e rdsD sel een(i pi wso t uet esp oznns .
e md ps e B a emw.S n pi mo sG u e s 'm oe AR g ob ofi ei a d y ecsg T O n aFib nBt aQ8 0ct .
ns ei c sh t s
s sa ucmh ac ,i t t l tf misedat nr cd onca t ra v nne N ,G i a anA9N em uweo .i gcerit c eati rn s oeoih ESE d gciC1Ft e o n d ei e e rriwt MET n cnia Btl cnd t gnru ceus asu tftl y pot a HCA CIC i iift ey ab hnn
- i asua es ieaowar d vur pt nt e
nl soisrn ed eni nicnah b e mmare cdc n
i krt nasw F t rinhl g naqP , s i ADB o ews rnecot uI o eoct gi a TNU autiT rnsr mdna ai p ihe mnn eoc nd l e pii . nnf gl TIS AF e
t sd e m . e rung s
't f ont i2 f
'et dl aio yeor ,c hii ed eer dtt rnnca arstl
- a - apse
,s oiinp it cie R smi ,eeden owiis3 ea rg aaceaooe prl d eupnc t aerr
,O ye a - vhet osd uaw smpc nhtl aoi arpe camm,wPE yuh mi k ot rnren SF sl yt std er Nl r acia it ceS el E egr b uopsa Fapst o u ti svst c i n nl bli s a yn eneamncsn U ards5N ,sC s B v sn ecaa f e)ii aorlil t au l f se , we S
S rai f peb ytt ae iunc n aes 2. d ae ,oc4 n et e ei r y hi ghdt o otl5 E' e t t e pi p ecr i gR gw c E n I o t e i s p5 G h osahSf ef(es
- i t ni m r gd t i ut h a t ronT di ht y 5 t nniT iy po n 7 k necl st a
nrP gT a al tt csrNd er Gcr S sro sd e o pE 5 he h i c u e ef et p et E cit uiNnes wei 8 e ,rrwowo st ei Y
arnrbFit e l ret aB dt nS/
gt un .C d .sb ea pst aot o rt o aars4 s u 0 ps t snvt neeoa R uvst net ch e i a gE 6 rvriD2 oisnenn h egpii s esep ecnl tl s l e cpt sipnfl n d ecm c A
M ecensrer eoes / t n si o l a riocl coo cf aeoai coeei errrf .
neroeoeif h rpeN4 gnsl et t cuiefh ei m r M irpctfbd o T podE0 nieeed n hc nsp t pch ut eh r pi ui s U e s pD vii ut ci S vex t adnssN 5 et cunt eeqaes o o eua irnooeF o - pi ooei hh eepa Edead gm Wpanf rBt Gswd( gw TtRf sb b
t c
e p
S n
) ,
ne d ot e i f .
u t oe n c t i uee t rrl n t ap o s m C n) o
( osc s C cn
- e N ei )
u F l p 7 s B aSd 8 s r - n /
I - eGa 5 n( 1 4 e e /
G st 0 4 na 1 0 A ou (
2 Vi q T t e t ad 5 n eca 1 e hi n -
m T fi 0 9
le .
9 E 1 b 2 l,
Mf J o '
. C9 u' N1 O -
~
I B S
- I e V g Ea 1 RP' s n
o i
t c
A e
v .
i d t e c
e ir h u r q o e C r e
n o
N c
s - m s f E s t o s G d td a e e i u g f s
, os - e e ni r s nh ,
n l
ay v s ed g n igt m Oe l s enaa a .d o e a S e bee eei ub gt rrI h - bdid r sd r N
O tf eo .oet rh vh w et a t
pd i e nn ed bd n yse e ecn p ic ee gt
- I sl dt w l r eenm ma .
i aer et na rai sv el dz on T u pk e l sra ond h u f cti e nl mh to m ed t Aiag C
A omcnd4 o e'e naar - nh gl w pl n Yhhn f
og ei
' pl P
rcloarn,9 i
bh ol mi cii s uae Tt odl eu t gc c u e u yt i st g h i .-
m r ql n h e s n r o yc n e s rt
,f tt E an cos o nu - ' l cnod v vienf gltti s
,f aas otarn T met ho nl ad l r a o e r gi nfh eh ewd ucst raeht wbsni ie ewvt oh eesa ri e vi .
t yohrn t eo t rr sn t a C or c. r weiAdh nt ec nh i t ,oidnerwga Dr iesot rs pi nssom oaece E radeea' u pi gs ereofsrf al rawdoil stdce R0 f goe a chc t nrwr .od eh s' aa oes i
Hl ugoent e pi f c R0 d sfedw rnodh udpsg gnniii t rcoi eArgy U4 sg 5 r t oifit sn t n nei f r nun hV pns C0 gnl n oeo ,g u f
- 2 nil o ,trrrnen l
N e A gtI t eers narni .irweiec avt r i peei tT a .
- D i waidore vi o t cd l h gt 8NY s watt epeweir FdV 8iT nne swmeerdranen oeenendhewg nesno ghi a m h ocnp AR g areal p bt u u g h yprnit a t . r i e T O n d i iTsu i st nwc N ,G d rddcpurd ad t g yi e t r iil a gyiss s nst wnngan
- i msoedl a bsr t rugel sna - ge e osn o oi r o SE i a EGT d tff nwl ed hf eeosaqnd di msnd n deh aoiseieuro d . cia sicsdc t oddwt ueeeidrr
- HNA CIC AD8 i
F l tl ssi t pmio vhsri dt aAseac n dl r ueaesh we e gt d e e ai ah 6 n s8i mp
/ o l
mt eande) l cg e
F p e u g pd e si e ne Vt ul u yh 'N 7 nrs l
a n n n 3. drt t TNU m evjn ar p biid gP TIS a ue ussTnd nrT nuaii F 0 gf u of senP
- AF i5h t s o t - e r o gl t gl1 B i o rievi(
R ssldw3 sise f anemseft .isva s n e 0 g n nsri pd d o s
,O miearf s na oi rc em-
,ni eh gawoa ed2ne nieur o r e mnnTd wo p s u eeey s i dca dmspag l i
- SF a h do tret aoo u gd e r e u tlre
_ E eet s eaet e p js t ga rth grer aP cv e t e a mvee.
U tV eo ctil yk
_ S ~ th eltt T scaueeel h td m . i e o s gh aersaeu rcetl sT oep pne nBh Dt yh e nn oc S n ancOlh wptd nscmnT ep l i a
eannl a
_ I i
o
.rrn ei pcom msHodt e i oa b5t r ei l seli cah agwI si en nrd .aeir nR g ny meem at ili a pP rp sgen m F t saea .o cna t 5se . u h v h e
.O aeffhecl .ar as5 yednl tti nrsenin t gt el r t ocl rg pden oou x niili o
Y un ect na .r e l uaNsne l ,eoevereee ds o eactl t
_ li sreeiceorn it w it canm nimomh p reed r nnia t
u al a v p ml ee a et gnit opeit e et o et reh sseewc
_ h prrel wg vnhrnef eiohli rel r d a
- H e i d g5 m e t l ci u 5 ohcpaie l e egt oemidtlt p
e ni h E e p rior rt ha ei m gcehfI t
U esl o ct emt vr i
uc i e e s r pd c e e d vtif q diut r ott u) nil ci S hianf nil oeee Net i cL Naf pid h e o u n o ph d e e u e e n F h o nnscO Fhemho
- Tdveoieecdrw ' Tdfsad st a d m gd r o B wn iiio( B cdiwM c
s e
r em se
_ a ul T
- ) tt ab d n l on cor e e l ne u t a s dp n f yt oern i oeedroay t hd p t n st ,e , si .
- o g l) rsel n C
nt al t cio
( acl rnnbi
- s iwhi aoeeit s
e u
N F
8 at nt r
dncddrf ul heeeecl mrt a s ie uirra
! - g tdl uett ne l cqt ss 4 i t eenennn ramwirI oi 4 euo eqs ,sne c 0 g 2 ne . ygt rn t
n idk gac nnail ert u e.wseha i ar e i e EIl( adcod m
e l .
~ E c
B Mf. t Us N
0 N2
~
O -
B IS I e V g Ea RP "s
- n i
o
_ t c
A e
v . . .
i d d d t e e e c r r r e i i r
r iu q' u q
u q
o e e e C r r r e e n e
_ n n o o o N N N N
. L .
d e -
B a e N
. , e l c e d L s
r sh eh s h o n ed e h a B , Ne o ac nrt ie . t cter i ce s et h . rnEd u
d eoi senrd e r s see S
N n
e hs c
hf w we g f eenn i rt ao t aenh t and ut e , e h r v e
c dreb vehi gG u
O v ut ren t eet c ct eio wooo n aw u sc I secipswl p est sf g rtb a d losoy T n (e 0h nd pen f nn n dr a t nI ah r C ee r jsmco A eh sr wtt o 7T al 1
9 dielou ruv ,t ncat oci fli omi el acas am es ieeecd f nne s ea nl t i b s .sna ht o t
E cc .ob et e a n et e iiet a Nael V te 's i . yt c drmoyc i)db r t d a t cdL v u bal o) l ncs autfi
- 2. na t nd I neit si nBdE g T
s hft1 n
reaet pc i f n od ervs ol a e e C ag i o oPci mp e - ,sia e3 d ee E -
R0 t A o y6 cV cg -
ennt iii i nndP ed Mpo bPsmar ut i w en s psas ts e3f
.R R0 O4 iT oP E
d r ntdii l d ,nF gB sm E n uo nsvo inae dd r - o l
eNosl f esii C0 2
f nrud(
.hl con asetdsi ,n v id a eest eoed) th csdN n
_ t u ehiehsesg adt rve bcaa . at uaL o D oeso s ssn ei h naaet ovrN h d Bi
- BNY g cve yt ht 0 sermTdt ss . ard a erreL t d e y t (t AR s 6 emea aet t eneu vpedB etl oCa T O n t wf ei 9l uh r enbdp a ,pah q a pi drpenD r N ,G i aoimx 1 ctf .si e h5otT e hn sr need E e (GT SE d n hHt e - eoo ae nac t0 ,s d gd no ud cie0n t t ne d rd ei h d g n - a sinof oicwr- e iNA i eh y e d mrt eiho s P g d e si c f sa e1 g CIC ADB F d ndi
.dt e h
imwt nie oatt ht ei t ssc eE nn rOiasr
's. e cef nd ne d
ooyr n ew8
- e TNU ue et esn u ea a rimcidlfbf i
TIS ot od ht At d ,t ssc t eoic t gt l
scresRh t wd rg t AF f sti n t neV ach meaP e5 eeos snnse aes R ve SF
,O mxeoh aecrw i
nme erTh ew t n gh woht ct se c o 2. ,ct d reu opr I nt ddg el vusand madddi e E e ap i
r eh r4 p
- fi e ah nrnd r
. nit sh t n nd icoden e i aani U tsl d diseisiaso Pod ge h t s dti u S gpon euec- ewhit n gEi nic f smt r ed nsf q S nn t a nqsisd l o nt aso it a o nsna e I oin i widf geatt yAbd iSc er . ccet osat yS r i
rbcndcV and rEusd ps eet ad ie srR F t a ni s aaenTt ae eDrt t pp he t cs tS8 O arsa eynrl ne s s e t neen ssnt r Y
ude r)t s d r g p pi u oi f q .e ,a ab nNseh se ao o a uroo n 2. su N 0 R
l c st st reedoi iEnmt g( oe em h ien l pi5d y2 a M u 1. i h e gnt t g a t4 nb -
A M
vFd a aenad ret rm n crin gti r uiaai vnaMi P e8e9l wl deef s ee e3 oauc e gl dE M c f u rl l iPt t 7t uit u htlin iuI ee U ed oP n N gercl evVi s A/aqraq t rade e s gS mtS S h nrE o F eh uueeeB ry V9h euh e l evne h eeN oiE TapN c B rt cnwL rDcs T0t rdt r AceIb N
Td rAscD L .
d e B a d
a .
e c yo n n n li ,i A ad et e V t e t ccs T , l ps aune ..-
- s l ei urac
) ng e;cv qt ni d
e en ei wece eset
_ l ar d nt c
_ u ww db aona n t a eid y i
er pt nl In ci ap r t
n bd l
ocat u n . ) r sm y o sr erset S e ,r .
C t o vt guc Ednt s
( esnqe Dioss s icd n d niej si u e e N l e owro N Nntd c u F f v t caf r L E oano s B n o r p B ( crI r s od ned e e p I - cn b re - gd pl a n ,ah nnoan 4 e goe t 4 i a
,rg rs t ra r ei
_ 4 ag is oin 4 esgns 0 n ehf ri 0 eenee 2 ei d gee 2 rw urt e in stsi gd t ea A oeit t gesd e n h r V nh ra n nrenh e Td T et cl e Edt at
_ m m e e l . . l .
E d e E a
B * ,-
Mf .
Ua N
1 N2 O -
I8 S
I e Vg .
. Ea RP s i
i n
o t
c A
- e -
v
" i d d t e e c r r e i i r u u r q q o e e C r r s
e e n n o o N N b c s l .
' t a e) l t . n eh a re s n n n N f e e et r0 e i o gL .oh t en t hi a8 c - t nB t t S
N l
up sw o s(
D no ess s it ,t i el pai i gg i iwr sud t r
..IO T
eoe' sud rrd t e nc en t
k l y .ut e
sn ga- 5 ed nGt o d - ,sn mii arl nn s n
a d ao rf QOn A
C a anw h g ti e C
a Ge ma n l .se rea ac rel r e 2 sr wne
- A td a uyim az 4h geo t 0s 5 y8 eee se-i r no b ft iyc u
yl n is2td onr 0a 1 c9 ud w
.E V u a n ritRa 4B n1 s Ait m c nl t o ei o PgnE ,e st s I va oc t eiiD hti on f d a_ no n ya sie i nR T - eh ca a hbl T ut ue nE ceo l t gco eC C .Rt d wiis awot a s ea E
90 d
esa
'e n A ,tbi cas ecef a l eaes tD inir ff esN h e pre s ui .bii u Pt hc a wee t re
. R0 V s mQ
.O4 oer ss T 2. u ribn a t oieNe f v) q ehT e tl t ' p iA adb r oer pe C0 l ga id 3t a nt n pi 2 ea r n - st n e crLd e B a emw.S -
xC o
dsd ie t rh t
BNY
_D
?
s vng ean da i Pnng mdps mo sG rS ehu . d r .
u e s 'm oe nd E oii ecsg pE tt ss eoy T
AR O
g n
dMi:
wn an a
d e
Ncas me cd onca t ar v oeoih nne a
pD a sR t l M .G i eroo pt t et D deiee rriwt udiC qe aen d os s N N l do fSE p GT n rali eel t rad tftl y pot a mmare dE e
eis eu HNA i wl oa l i uhne . eni be we df as rl ,
CIC F cfd ed".
vn l
dt e ah t .s nicnah o eoct I
gi cd c a aiwn o
c2 eu ieh nt en8 ADB T: U nNee n
d eas e
e r
cey ort np l e pi i arstl ,s
. nnf gl o ii n p' v t i nei ent ri9 e 1 TlS o h mu sr a ruii a- apse it ci e en ndoc wsy e' AF - net m deu P sl d eupnc t aerr ri oi u
,R - h o l dd s nid - .
nhtl aoi a r pe yr sar SF O itdc s ee uie ouc n gebe n as acia ti svst c i n it ceSel ms eel t uvns t wo E t wir h go i o. ilt s sh ecaa f e)ii nl at er saon rlf oae U
S eof enid s
t p r tt au rl se eier t wet ecr i e pi p c gR g w t o sh
,c o p B
.S h En p i et
- ssna t n t n nad do n
ewtd n
osahSf ef(es po n ne ,s ro I
eve d
nniTGcriy or est e n .
I e ee i , , a or S sro htrr Q s F
O e: d t' cSI n mec el n ns u
mo gd y net y ei p et - st ei itQ t roe Aot e gee rt o 9 ps tsnvt aA opw Cdn nR ol Etil aars5su neeoa c uC gpe e Y aS m arr cc nl e . cpt d ecm l nery nsm R mN .e n e e reitN si p n fl n coeei ad i r t ege R r() v o G o Moe arf re ambaL cf aeoaI errrf . ve d Qi enr P r eeauB ei m r r pi u i s et rtAr tii M f5t rG " f r Su ll rq pch ut eh ut ci a aiC o ewu U nRp p Rs cpeer S et cunt eeqaes el gd j naq S oSN e Ss u m pd o - pi ooei hh eepa h e eu5 a re cN(l Na Nioaf Gswd( gw TtRf sb T r R a1 m iNdr b c t
c e
p s S
n e r em se
)
ne a ul ot t t ab d n e if t oe l on co u c t t e l a
nes dp r
n uee f yt oern i
t rrl oeedroay t ap hd p t n s n) om st ,e ,si o g l) rsel n C osc t cio s
( Ccn ei int aclal rnnbi e N l p whi aoeeit u L asd at nt mrt a s B r h eeeecl s r- n dncddrf ul eGa ie ui r r a I
n( g tdl uett 4
e e ne l cqt ss Gst it eenennn 4
na ramwirioi Aon euo c 0 Vi g eqs ,sne g 2 Tt e ne . ygt rn ad t
n eca hi n igac dk e.wsehr aiaei e Tfi nnail ert u m EIl( adcod
- e l
E b c
~ -
n
B .
Mf Uc N
2 N2 O -
IB S
I e Vg Ea RP s I n o
i t
c
" A
' ev i
t d d c e e e r r
, i i r u u r q q o e e C r r e e n n o o N N d e U .
e .
d n s
. d e e~ sm t oet o td nest y
r ,
d a e r se ot gc on e g e ug . , - of.rrcad f cnent e S -
rn , on v n s s mp l n t euijeae C
g ere 1 t a .o ea a saedpa il rwohl b n bue h c hhde n 5. ie t ero s dl t arwu I i cb 2 ec tC nl 6 c ct i n)t uesrp ge T w t c 1 c sy ab 1 n i c eev Qri5.i aBnd C a oot - a yt d sg o a l nae o edra A r n e Al ria ensr Ap f oC ps6l gecnha h de ney e nm E
V - ge r av cat Rpa sdr nsnl iisp fre ieny Erce ni ot nrr - n caeauAo e1 f ioei rsbsne gtmn id n
I snw o ,i eaa ceet es e eirsa T
C ai rs s h.
et n 5 yets c enti pi e l id ce 1l 0ar ueedKc t ye c e et od nat e ae g ,
E . det iae 6d nii s gli t vu7 ods ih gt sne R0 eer ch v 1 a s n pb cg eeo rne gt h naear R0 l no nt a - eras an u n U4 C0 fi p .
I ge1 e
is
.h Arobg f n
- 1. E otmi ri se Fapah t eeur gil gha nc 6dcc P wa sh re1 s .
D 2 J t nr8 ne 9 ce ,
ic2 Rla
( egw ni - n P a gr u
dr it . eh evt9 c .
t uoeda nsneehoes asengct re 8NY s e Q1 f n8 edia E nt rd e , s o_ s P- e) i in ug AR g d oA - ee9 . 1 risr N)i s a h sa g l ga ,gd n O n r9 T
N ,G i tCr e
di1 e aved swn d g t g8 s a E r nel nhrnea ESE i
d eeet c' s ei o a 6
- mr n od eRao nn n thNo5 i h e e c ei c h MGT n rusf P apeg rCrc ai fi ac ( c- dt w vdoc HNA edea sftB ee uFd tt owtl N A u t eenr yrDfRttEso i E r hi
- d( f Sr aai l dd arwoPd CIC F w h hd ra N gdt s e eo o ceehaop- e AD8 dtd t on- e csv ep n yiota ' , rafd t d c nt pt Hs
-.de TNU se e ot en t e i yo ,l yd iao a . e TIS ttf u fnrD 1 p o rsio nr drAcrign AF raos s oap s e Pehi o i oC ef oa ,l t l eurei .rse t n R ol m Q 9Qenh uct ff l d hvnl snvseedn 0O peti e sA Al ot gqau eo anSceoo , t aest ueeg 5F ers t eeC PCci ne l l vee uwcd1 rtdiirimn E . r os asn E at n iRoo l s vDso o os rtf ei U
S yMR ruoe a
Neuai r ts ed e Hhh2 pb t ec irk yt C h h qt ee e Bo hdNd ct1 euoh eti a S
I Aiisn Cl - .N ecet ceh st enn e d eo e g)r inns ct h
t anEie .smA ue - rsnt ebsum
,c uq nbt o rdami aMe ie e Qee nojer F ebeo e t unnut . ghCh f m n A ef5 hi8 y e E Avreat rof O rd yn d aica2 Iviii t ct reli e ot E nCEt
(
i cs iVtt9f h mT n1 Caert h w o pd n n d
Y f cnc uil c) ydn3 d e eeps r d e it t , n menage R - ueu yrir cf ad eiie o r 9. i r se-P f rl st aeea ss ened one1 t ewit ed6 e ,srcu ic M
M t t ct rt cr p5t eeE leici - e eee di -
et necodsa t r gh a f eel nsis nee - nprN Fit er d wie8ivP dd p U
S enf n e a pt woeo h usn AAeop V d ren c
uf on ti td t vv1 oE iroit psrdse I cdc T qee TRiPri -
N oNi id Sa oeea9orN Tb rh1t p(
h eeunaern T rdFawnoi d e y
l t
n A e V
T , T u q
l
) s l e .
ng e; rt d en we f c e ei e u ww db l
ej i
n t a eid ro t er pt ner n bd ocawp o l u C sr ersae
- ( t o vt gi h s cd es nrt e N i n dnie u l e owt n s
s K f v n t caii o rr i -
od ned ce cn b t J
4 a n ,ea e goecl 4
rs it rn
- ag s oad 0 n ehft e 2
- t n
e ei r w ea h r d geps Aoecv V nh ce urei
- l E
m e
T d d
I et ar e
Mf t e N
3 N2 O -
I B S
I e V g E a RP s n
i o
t c
A e
v . . . . .
i d d d d d t e e e e e c r r r r r e i i i , i i r u u u u u r q q q q q o e e e e e C r r r r r e e e e e n n n n n o o o o o N N N N N N
Q . . . . .
S a b c d e c e ,st l
a d e yy e h i
f h swo . n o
y n A tt al t eenma i sb s i Qn i r S
l c i
mno me ary ri t n n m g df o N ae s e uvee i d t n ios o a Ai uod eeb d ert e n i x V s a ne 0
l icp snnit t sh t m d
ere wn d sm t ott etT er wer n ge l c it aina n doeeVa I nt e aoh o a . i l t el ea dhi C
A hti mwy oog ic puet r c yi ye r nm uamu rc .rnt v cos ueb eneci ine t l n sh a nk iomo cl ec eiaoe e .
E l url . wf edvnrer V
t
,dovd adl hA T u ac sc acuad tt I t s ,dee rl una l a cV w eT e l
a eh e i vA cl cce ao w eg i rn snaef vod i Aa uo T nas e u a ,s t .v t c rV rcrro gi l e qc C
E eensad v a .f se a eT o pol asogyc .e d roe e es t nat d a p dr rncnmd n R0 R0 naihhh ns no ne n ua noyno dl k ceti aeaag O4 e tT cc eow eit ah ay s edb ef amnrud e i pd a us hie dt al t mb r vn v p o o u qi t es C0 eec s tti nahp l o ed e scsev be 2 dti . d av el t y t w an f vef r t nd en D ncf st n yue pu Ab oe o roe oo BMY AR s
g i
leieua bl r a
e gd V ni ic t fi w cdnea ang tit r O
c gb y
d enT y v nn nousqes raiff ot T
in d eea d vl nrt c oe h e o t soonamd N ,G ESE d nspk o scwa
,r eel v a i ora yf eu d r cm ee i
t erpr wel e n" e uen MGT n aes . oadt esl h e HNA i cf eol pi sr rlt eae db n
h q st e t sa tir ai mu ca rca at v CI C ADB f s
( nrt ece a vee scd odaod cew a ng en yu icvnad eexe l ranwv rsopa ede T NU bi bq ifRhw eco u d rs nt of s ren onl er r mi e oenl uneua TI S AF "wit ht a ne ni ha sit ol ew sr r .
eeyop f r f measghou g sci ( uIf a ro n ovisitf q
,R O ieac d n wer q- c l ioy vtl f s t as u e ph e e e
.di iul r anwe o en E
SF
- o n vl t ocm ea iet to "sw r en qo t o ruoeh dh e ,dbna eysd U
- ued vhi t mh ef at oq i t set sr o i R v ,esea etd iet nrc r l a f ed v s e d di e S
S t
a esr gpn d e R pe oeoe w ul deet itt anevnet rV I c l
ann i n/
l l dl e vnmft e t r ee l i cu l g samra e r h d ci ui nw e a w a el s i
cair ef a - a R ei e r b v ae reoAt adsaosiuny F f i wodh e cnc rmpo ae cr ubf ne O i r
csa hi r ,ewlv a n iii n
l a
amon f cr d eoe r
.d Aii e lInvceb oel i f a e Q yna cr .i rao Y
A R V e
T c
e) d i oe wnrvrh al dc hdh cec el e c)ced inwAb s ee we l r po p
o r o we rrsam ct pt n ci Aee Vhi sol t rsr t
l a s ct M t " egeni c H
U n
e iiti un qa T at e-evn .
h eV cit ei ev ak c ieht pai rr e t e Tt ct rurot o iit codif
$ d evsi neereer v v ee vi A pA n t edf dnl pndr n
h eo1 T erae hh ee V pV oe h neuoaeeue T rdcbrb T rnC " roh r T c Rn T aT cd T ad accrvap e N p Q . . . . .
e S a b c d e d
n I
/ r d t n , t s o rr e rogean s n f ee w oninl e e g d t g d soum c
o i t ly e f n ie nredce ss - m aa v eed l r ee i r h e vh tlaE P dt d rs o d r td oc nsal f ee ft nn h w ,poami er mp y oea oa e .oc i a d e ri i
v s - ewrt cesepe Inp . e op l
l ner,ret y o e f a orl aeu er i d . )t rd r i al vq R ppavd ) d sa ee e . t asie) n s
derwac eel . nwu oeq pw nn as ntS .
g l nv e eo cnt ga 2 i aailieit re cie evd si i v gi s
i gail n fi sei5 s
e i c ,eavo ccet ,
sea
( rn wr e ti ov irend seer d2 0
D nseirig i e nr edo se ht rn d n sl i e e v d resd
~ s - cn h eei wae vv ep e eet cr ea d ousn u . . t moea l
iecr ru t ntds ea s . unt
,l ia rh as naonsr s ,c l e t a p vn . e neid1
- 5. . eh e ss sl d s v d i
. 4 soot ucs gd d n b i rcl el larn ceo na nnr l a5
. 0 w e n , ioc eoof a 0 l ti iki i pi one2 2 dasddnh a v nct t n et e or
. t. nrgerei ienecs lCtnox nea lah d at sias
- n gea p i t.l nen chl ecu c ue c inl a rwt uueis t
e.
_ it k eu g hdK t cqid no
- m. sicd qnn cn el lct Al evd op e.
. l eraneoE Dcpi rn(
eet oh a ay V ad eAie T pa Nt c Cb T car (tR
_ . E N
- Q . . . . .
. S a b c d e
R2 E4 B
Mf
_ Uo R
NI 0 -
1B 5
1 e V g Ea
_ RP s
_ n o
i
_ t c
_ A e
v .
i d d d t e e d c r r e e e
r iu i
u iru i r
r q q q u o e q
_ C r e e e
_ r r r e e e e
_ n n n n
_ o o o o
_ N N N N f
g h
N B
W a g A n
l s
s V e y e d h c e
- i T l v nl r n e ae i yy wtdA eauW ae . id h u a s yr f al h
S na ul s i , t d ,hah e oe i mno me t
ihlT e t w nps i ses uh l c ary N vtl yh e ce iga w rcVeA O e ie acel yT t qT ae s e eeb re ahbWb c
ah ft rv s e( orao ne icpsnnitt sh t m I
nTdt h ruuu , eS d
T C
c ei o d oe eaa ec t s pd nq .si . n ge nt e
_ nnbhd .l at r d t rei l eae5t cnsl hti mwy oog A ge w su os esorl noecMS7 niinl .
- E id y sia ,t ot o nw f yner l o t v n rl iyen gf iat rso 9 ef erse1 euett mfdi oad cosueb eneci ine t l V evmn e oo e t
,dovd adl
,f rdo t nhP eh w una I
T d e od mt li et a it el s pvt o c noT rt rrss aoo t s ,d rl ee l a C t eCt rih ncl k enac pnst a uioa oc S u ei sl nl nase u a s t c y nb uk eu eensad v E nl aimt . deue s ml yo .Ed Deimqcrct o l ,a
_ R0 R0 O4 epecum,o d mhi qo naTf ecsi n ii qh r c eing t ub n sr) t adNoscrld ah c eeadl af d roe naihhh e tT cc e es eow ns
- C0 2
e ps i r r moa nt yet l pan exh g p
i s pe ied s
,reek o nseE rae esc mene P l
Des h eenet act y l
pda eec dti us
.s d hi e tti D ei . et aic t eti osocd ecehEl ot rrot c av BNY s d d vorti a ncf st n yue
_ AK g nee ngaf rd
,s e y
, dine hA rertOet ine w fd ua ai cr i eieua bl r T U n irmn cgb a N ,G i ergsrur ol i u n gd can t rtscV eoIi T u
qeeahso fse roesci5d 2.s i t d leea n s pk ,r.
y dvl ESE d rh oii p c e c io f n e eei o scwa MGT n otf s l v aynd a ehr t airoh0n v a eb . rt s rert2I e aes .
HNA i f red ra ci sx .r t e st , ,pt p r cf eol pisr r)t CIC f ded nocn ynao et eocc e gt n)l fd oe s a eae ADB t np a g aert ol rht ei hnnesal el ont w t vee scd TNU na t ,ri mtt t pat pt ti emP ual a a ( nct ece bi TIS e nn , sos e m- nsc ois ren onl AF l
hmuE nu us es
_ R mt eeodd e eseddrnd epl e uman t
nch oe'.irrp gea gsuc aned e1 ce nicokMahil Mt v p5 eu nr "wit neht a ni g sci h a
,O ribn ae sonn a tAs il odo ieac uephee dn wer SF ix e yd v t scoo t rf es s pd os i m0dd et o E ueepl n sm vl t ocm t
_ U S
q veeawe n i st r is refIdid oh o hr eoec hB eesd a2i e rcsnx v c ea Rv ,esea
- ued ivhi etd S
esad nt ed ei a e pt - nrt a rchud uneI eseo esr d e R pe I rehi l ds o nisint u ,ep ve h
tt u cp mieio i et f nn d dct sed ar da R erd eerep t r l ann i n/
gpn l ldl e
F a i d s nad I a a nn cud mmom cair ef a a O r) wdosre enrn h ,ee s t et t r ii e o s a o o p o g i wodh e cnc Y
usio d rvctiti oon d g unl f ooal l i sszn t
i ie gd mry r
.s so efddtPAs en(
h rs e ,
sS esn R
ori nsa hi r c
,ewi v h iii n n e) daldc R eeeeot hi ml il nreer usb u P ysr .t s e hdh A ck rsnasd tt ra aiaret dliolEt sel nl e i oe cec M
M oc l t n aou e r gd i ns eirf aNievl ean T wnrvrh
" e g e ni c el e T at U
rehasuco nuf q l e n n ui u cac u l ceam e -
S phc cuooel e egec et vifi s i n a a q gd h eht enn ot seneaowt reerah uroel a n es ig evsi iiti un qa evn .
A( st d res Esod W gcsrei P d d a M t n ph d E we h eereer h eol T rdcbrb TrnC N
f g B .
h W a s .
n r d g e e e is l n .
l n
g e geip lo i t lys d nvgu r l
ieno ss ii t t ee ra n el er b g nn dtd at e " e oo nsme d ic ,poaid n eEtt t T .oc r e rS a r ay s - e w pl
)
p a" uo cl cese a d (d p e e s ap i e er idi u d wsru ft ppaver .
n n ia s ewo) i i iengs a ru eq d eret .
t l nv i c n
o t .
ck vif e ecop ve d
aail c eaeee ivdt ri i da C ur nup n insei ,ccr
( d o dh e ,,
s e M nw o ncie at o
ht rnel g cn h ran )
s u Q S
cs t
ael l s
t l
isn N B
eet caci t moe il 7
8 s ni se W ti k yi v untt nl /
i - o cb x lyr a
,c s ootb cp uh e 51 nf e ) o a -
5 o hdl n ns gdd n es /
s ceeK 5 w e ,t 0
4 es ae d asdd - ,
0 ow mn/ s 4 ienenh 1
(
2 de nrnA ns 0 nrgeros gooV ge 2 ig t ek a eu pi nil i if sI t Av ic 5 n srr so t sicd qrg V e eeet er 1 e T r Dppa Dp n
e era neon D cpirfE m 0 e m 9 l . .
e 9
. l .
E f g h a 1
E 2 II iI'
_- B Mf U o'
~
~
m -
N _
5 .
, N2 O -
2
' -. (
. IB~ .'
S I e N 7 gw-V g
_ Ea ( - <
RP s -
3 n
_ i o
t c
A e
v . . . . ,
i .
d d d d d t e e e e d c r r r e e e i' i ir i r r ^
r u u u u iu i
r o
q e
q e'
q e
q e
N3 q u q :
e e C
r e
r' e
r' e
r e
r r -
3c
~
n n n n e e ,
. . o o o o n n N N N N o o N N ,
'.c b d e' f g ,
l' g A
,s .
a y . k c n l
e
.'s w t . n b ee V eeom o ". s s rh n s i wtdA T . l v ae .
ns
.rina t n B ac a eauV na ul s 5 uv e it n on o s hlT e t w N deet i
- e oi x sr rI ivtl yhe ce e I
O l c err en d
d sm ititt idro o- e ahbWb ah i i
T aohwo a'.
it at na d eo f e re c ft rv i qs r
i l ael ntd y c ceio d oe C crc i 'n m ul mu eanf d n at r
.amhWd .l A i n
puyt ye om cuec pl ei e e a
.su os E hA sea hu nk ac i o l crl al ua pevrd wi Ar - euel $
g$ ct o nw yner o ur yMl
,t isc f
,l V
I T
C t
cV wTl eT eJ av
.f .e eh t c a
e vA rV eT cacc r rr .
orpod co ,yn , v.cvm 0t ot neo l i p
& S. Yg~n l iodmt et a e i t el s ncl k f
l E
t t nas da p do de 5 eiairc Rf rh t eCt rih enac R0 no nl aimt . deue R0 O4 eit nh dt aat t e n ay mb s
ua r
ndynw enb eo ve Faetded C st l rn epecum,o yerc dmhi qo n ii q h r i C0 nahl l o .vd vl
.l 0
1 rreo isCaa naTfecsi e i r nt l pan
( D 2 el t py pu t w oe an c
f ef o acrwsm ps r moa exh g 8NY 's e gd A b of rof ee u t a ei .et aic t eti g ni i t oi sll ssnr d dvorti a s T
AR O n d enV y oe v nn n owqer use ocoaieg nee ngaf rd ,e
_ nruT c he cm purehmo i rmn oli ung h N ,G i o a dr can4 .
i ieel e mnt mt ur ergsrur ESE GT d
n db yf eu mq sa ee t r tirpw av i
rog o n (cp r h oii p c e c i c P
HNA n soe m otf s - - l v aynd CIC i
F odasd t
ng yu i
cenas socnnde f redra ci AD0 cew a en iRexe ef i g c dednocn ynao bq f r ntit n t np a g aert i e irr~fd : wheru TNU er r mi usgusca na nnt , sos, ri mtt TI S sitol ew sr drit ear e e AF R
( uIf a q c ro n eeyce eosidru m t' eeodd e e pl e l l
.O e di il ul ioy r vtl
.anwo c cdet ondseas t s eseddrnd ae uman SF "s r . en qo re ribn sonn l Er w t mh ef t o ruoer at oq i p nhba i x eydvt scoo U
S et nrc r l a f ed v pveitC gnt hr,. f y yqv ueepl n veeawe n I
'eiae i s st r S
I i oeoe vnmft e t r ll ee w ul cu l g samra e
deet r h i no oo .i rf )l t
rnh o adnt ed nisin it' ve h
tt u cp f
Reier rmpo b v ae ae reoAt rse ysa l ds u ,ep i d s F cr ubf etd ecnu' a wdosre O l a
amon f cr d r
.d ennl aoq r)enrn d hg ,ee l i Y
i r
fa eoe e neUb ui u si o oon unl f ic) s ced l
o ct pt n i m iqt e . drvctiti ooal R ee po r o ci ge R h eV nwAb w e
p ak we rrsam nr .seatd ndl ae eeeeot ck rsnasd himl tt ra nr ciI ei c ieh pairr e
Ei ump soauut oc l t n aou u ev vv ee vi t
A pA n t t e c qi renasuco egec nuf q S T erae hh ee V pV oe Aqeses dd V et eh re ph c et .s
" roh r T c Rn
.~
I aT cd TrirtQaa ' -
cuooel e A(std res '
vifi Esod i b c d e f g t d s rrnn eooi e
w roge o ni n t n .
p r e
d t pi e d so s
e e f ptd l n .
m auae i
v nred - g ei p eed s N nvgu r sms) . r e vn t f
o d eeoe2 rs td o r t ieno el er er y fi nn ' n b g mpf r1 oea " e de np .
rind opid0 l
l ne ,e r f' de.- .
eEt t
) i e f a2 a orl a ~ n rSar d )t rdl 2 r ial e
p a" uo e eeas (d p dsa e . t as .
e s ap u nwu pwnit nn as .n -
o wsru n oeq eo r eo cnt g i ci e sii e o gi igai n engs I i a t evd i vt up s fi s n sea ei s e ti isee t .
vif e ecop o ( rn wrdsR ov rend ck ri
. C i e di nr edo ur nup i
sl ep e
( i eA - t v dr
~
s wae vv( sn o do dhe e N ea ru d nw ncie u 8 iecr i a i e as t ntd naon o aell s
s W vn eh e rh .hm t e e ne cs t s t
ni l
l ss l sl ds v ti k yi v I - rcl arnoE na nor o cb x 5
- el ceot oc eoof nf e ) o l ti a v iki r ii pt o o hdl n nct ea t n et e s ceeK 4 ct x heavB ah dat s es 0 mn/
2 i no nen chl i eC ut s lue c Inl uueaw ow de nrnA gooV hdK t cat ct cqi i if sT t cn ell t l Al ev Av srr n eet 'oh aea ay V ad e V e eeet e T pa Nt crW Cb Tcar I r D ppa m
e - .
l . . . . .'
E b c d e f g
,([' L'l
u - y eos px cy rf u( .Q -
esi g st n
)' smeef d wia hi e ee
.hh
.M m$h:j bdia eai e N2 6 rcw i vT O's*"Crvett el .
eov vronn O - .
ldf r eAhld pb oi IB
& g?_1 i aid rCtl nnpap
% .S I e
.# ~
O" a r ( - i aga uy Vg
~
~ ct e) ef w i d c i avM ghI syenn Ea -
s ifh 8 nt . edD w "e e b i e e
.RP n t t n(
g i
l n .i a fti nit c O3 i o (' nnil eesa pi R vM m I e otii
.inrf t
c .QT Idt ei adPr"l se eaid t ewe d
A itdr e ieesusie e - mrft efhh odo b y v . , h ewoa hitthi ps vsgoa n
i d d d
. l m tt
.ng ,t bek iint t e . e e obcf f eneeddi g c e
r r
iquP" v i
r u =-hm r
i ~
u r
pll ao I dit nn e
i raiirai eum or wso f
gg- r q q' aitl l l nswqre dRr y
o e e e wni i gseem1 I e L r' r r~ N eb' mnndt a MP v F) r g
- . ri a a e s 5 B / o M
e n
o N
e n
o M,-
N Brae tP po A( as I pm ew t art erooohEhAi Ddf ntt NtCd d
ePeQs R c
'N
. F . . ' .
h B e b c t.re .
s l
,x : oh .e a
.L ft d ic yy
. N' h )s - . n s e f al t wAe m o - e t t :X .
5 L
snnR lii l c i
mn o _
e s'ia y !eV T av a i e t nhoeo ot set a N O
i addh e ae cp s
t sh e . e .b y er o htt i d
i t h asd l h I t ent ebu(P i snnit n ge
.t d rosnn w o d
a .
l at auosga n
T C dio E hti mwy . nto9g e l ,eei r i A rflN cosueb i ne asirt ye ral bi hien r
1 .
E V
dec nhseue
'aternh daat a
t ts eneci
,dovd
.dee rl t
adl una l
i cevea nur rewu lac ya nk e
evdt wc t ee a l ai
,rt
- ; I T nase u l a a
hd eh measdc a y C ils s f 's M d i e sad v ,sa cehev ecch e t c a
hie ft t ser E' saaesn r e e es t ouT da o ,iamp R0 R0 U4 yt( rea l n ur aosdu ,
- ;a@t cc
- d hhh us eow hie ns t n
p rs - e n a y' w.ht mb l
l - 8. i nco e
sy r .
, ec
' D
.C0 2 ncl edl a ocea srocu iti .s d tti yue av eAes dVft y nT nb t w oe ib3 2l mft s 2 us aoose ur 8NY s ntt ron lacf eieuast n e aa g T
- AR U
g n
gnnpra ieo P
.:" deea l c gb y
bl r dvl a p entpc l y ni oe v
d nti nnnd irvI oie sd u N ,G smce n s pk ,r -
. .HNA ESE GT id i
n ee dryeEn irhD sSn m' o cf eol pi s r scwaaes .
eel v
rlt eae a doa nihAu I ttV q a T e a dr t
sa poi i pd pen Risvt p i .
.isde m CIC F euaT m' s a vee ng g eep gy ADS i [ hqs t es J (nct ece sren scd bi onl dl d nunra en ogue d
mi nt exred nmo cn
.T TISN t Nn 3.O eac- Ni ae ol a i
g re
.E c ni ha ceohl ew weabt ca N AF c) t nt g sci erft a ro ems na R nsedhr dn wer s oci il i e e e l
Sf
,j isnetP1 se c eo - sP l o e ph e e wl t ocm et o t
( ys b arn ul qo vl eEh eqti e "d uoc M- scensEl eoh eaOa u~
aa - ued ivhi s woh ef r tk c csyc t
Rv ,esea etd wd N wE I 5 rrt r dp d
esen gf t h a ,[l esr ann i n/
gpn de l
Rpe ldl e
eet ivi rIdt f c r e
e li w
ee i B ahuar nFtebra hCsrp F*
O annentM sih oi r e m ,s icair nsa wodhe ewi ef aa cnc iii euetof.mr Rq ro ae bv cr
,rt" no ofdd ooV nnA t
Y etssu) e hir ,v h n n l rnf i i en cT rait csr c dal dc hdh a erd l r t st ad R ucl noP u e) i oe cec ct mee po i go est E di p e d E d ef m m e T wnrvrh
" egenic el e Tat iot pw nni e p
air d
n n "e r rin e
T di P ciouhk c orcccoo iiti un e- h mni r c awmd te sr S
U recouor evsi qa evn . cemev ee a a s ei r Pv&dsBP heereer T rdcb rb neol eroee hh nr eicht u N
T rnC T a cb r T C I dl* oT c
. F . . .
h B a b c m.,% , .
2 d
e -
rr
- *l l pd on ys d ee t g
' o ,ec o ll e f n r ii m aa t .re ra
+-co an sps c sme at r
o d h
f ee I c
^ edaaid er mp ~
g%n t ay pn saewpl r d e ri
- g' np . op
)
Icl ve a I e f d e l ,iidi . )t rd eY ru ft asever) ct cewo .
dsa nwu ee pw g% -
wia t
eq we inerl h m neret c vd e ii t oeq ci e evd si^
i v e
n d cut aee, sea e C
o da n
ecocr ,g ( rn wr --
( at~
t oni i e s -
s ,d ohrai nel n sl i e o
e u
n sM N sadcacl wae vv ea
, C s e i '
F gi e il iiecr a rh W s e' H nrstt ne vn .
s yr ee unp eh e I - l a 4 iwt gtb cs rcl l ss arn a
g
- 5 ns ae 5
aian rrk e dccdd
,t e. h c l ti a
el v
iceo ki nct
_ 4 0 ns s 4 nnperoi anens ct x h ea gc 0 ino cnl
, 2 2 gg pi n l nen ecu i c ii t eu g hdK t c zgxy4 w % <6 t m
n er e Dp se t n
e sssdqrn eeeneoE Ddti rf(
cn eet T pa oh a Nt c el lL m e e
- 43vs$s l E h k
l a
b c
m7pu
ii ni Mf nunRt .iw ? ' s' Uo id eQi rs w z C 7 eii A s o n a e ~-
bvcC of orc N2 ii p idn N O - sdf ysnt a IB anenioat d t S
I e Y g E a d
id adi u8r eeyoeaat c tl o J
s mnth cvcc RP n
if aa ti eea i s e f j i
o t t cti rb n .
necncroui t
c eheeee/s idt rrl vdnl d
)
2 0 - '
A r ef e e
yof enal n gb cerg ao F N ,H v n r is i B . . - ,
i i* o oswrt d d .
t wdt at eeei 5 e e - d d c ae dit s 0 - e e e iru rkd gd vf o ir ! r r
r d cenegeap esisnr s 4
0 q u ~Eq i u
C o t hidii t
ECv uvd eI d Ri 2 r'
e M ^ q e
r q
e r
el errP eO h" rcrau nvT e e e cd n gt eeoA n n
~e aneireuh E ab( orftb e b. (C N o NNo ~~
t o n o
N N
"~'
3
- d O'
u f
g
.- ~'
k g A b
y' Qe b xB ee c
s i n V T l v l
e t
I.. s na o x rh ac n
a wtdA na ae .
S N n e
oa ct !
sr s ieauV hlI e t ul s w
O I
is M ih tt m i
d nd ro ri o
vtl e ahbWb yh e ce ah ie
__d eeo f e re c T
C A 4 ns-oa lat t
ulsnae ct ec ael h mut 'panf pt d y Al ei e e a d n c
nnbhd ge ceio w su
.l d
ft rv at oe r
io os E
V isc dlcrluan d
,r evrd wi
,euel i d y sia ,t ot o nw f yner o
I caccu 0 - vl i p evmn e i ,l f
T vA co - o 5yn cv m d e t el s C
rV eT r r, r r f 7 po t ot neo l iod et amt nclk E
R0 p d o d ,
Reiai rc Ff rh t eCt rl h nl ai a t , enac deue R0 ua ndynd Caetd ed epecu n v n ii qh s enb ee st l rn d mhi qo ,o r O4 r ve vw 0 i suaa c C0 l o vd o rre naTf ecsi yet e
eeacrNsm 1
2 an i r nt l pan D
s c f efl rol u t a ps ei .ret aic moa exh g BNY T
N ,G AR O
g n /
it nn h e Nf owqe oi usf o sll ssnr ocoai* g purehmo d
nee d vorti rmn ngaf oli t eti a
rd ,s e i
cm i eel e imnt i
e r gs r u r u n gd can ESE HGT d
n ee ti rpr n mt (cp ur rh o ii p c e c i o HNA i ,, - t r ~a v me rog o otf s l v aynd CIC F ,,
yu i
cenaw socnndc f red ra ci AD8 -
.' b q iRQxt ee ef r
i g ntit n c
t np d ednocn a g ynao aert F!NU S
. sr e if' r .r fu r
usgushr d rit e a na t nn , sos
, ri mt t e
A" n et l A . oy eeyoJ vtl e e cdet o s i d.trus esedd rnd eeodde epl e u n an o ;~^ an4c or '$ sens f
i rib n ae sonn 7%i t
at l a ruocA oq f2*
i v
r e pveiWoa h
n C
y i x ueepl n q
eyd vt veeawe n iscoo i s st r
<Q.
ul dG e gnt ri t esadnt ed eiae
. I _- - lcu samrt no oc .i r e h n i si n h cp
~_/ e r a g rf ae irse ys a
)l o it ve tt u reoAh l ds u ,ep ids 4ir -
cr d
ubf r
t et d ecnu a wdosre h ee ennl a oq r) enrn g ,
" d l f a eoe . e . neUb ui oon
- J*
>- A 7 s o
we r
ct pt ne o cit imge iqt e .
. ndl seat d usi o d rvctiti eeeeot unl f ooal hi ml M rrsama nr ae U
M
- eh i t pairru e t eq Ei soauut ump c qi Nk c rsnasd rehasuco l t n tt ra nuf q aou
- vi ApA nt e Aqes el ed ph c egec S -
ee V pV oed et s
~
V et eh ad u cuooel e vifi R n T aI cda T rI rt caa A( std res Esod f
' ' d e f g
_j d e rogea t n . - n g
s r
w oninl e e d sou i
e c~ i v
nredcy s
e l
g ei p n .
r e
eed vh tlarr d nvgu ieno td oce - t el er ly fi nn oea o F
s -
' n e
b
- e g
i ) C l s e~,et r r n d n eEt t rSar a orl aew e a" uo
^
d .' r ,ial vo e p (d p N~ u e . t asir e s ap l' nn 4s ntB d wsru in eo icnt gail ga
- gl n) n engs i
t ia Y ( _
fi sei .
n tl i seer vif e C
5 ..
- oy rend d .
1 t . ecop C ck ri v n i
(
edo se5 ur nup v
ec d res0 s - d o dh e
' e N r d ous2 nw ncie s
u ~T i L as t ntdse naonsrt o
cs aell t
s, l
_' , e l
n eI dr s ds v t s ni Erla ti k yi v eoofloneR ad o I -
nnr ap _
o
% _ oc e cb x
,.~N^
5 nf e ) o
, .w ' , li pi 4 i t
o hdl n y 4 0 i t n lahc et e dat siat or ;
es ceeK mn/
y~ , 2 t
ue ct Inl a wt uueise cqid nm '
n ' ~ -
ow d e i
nrnA igooV f sT
- 2 n
w lay Cb Al evd oe V ad eAil T
c a r ( t_ E -
A v V e srr eeet
' A':.:e . !
a T r Dppa
.E '
d e - _
g
' \
- f
B eof cemoh ig Mf
~J c hf rani , rs T r el pes .ne l
8 ePpge p nug mnof i2 f .
rnE s siet nsio 0 - deai 1 8 eh e sirrae .
5 euzsl I e irtlcihse ,edi ue Vg Ea unu spnen n qiN1i oicaen RP s e ll g o gh o n rdsnb enrrt s o e oavepo r i
t s b 'A i t ii Vssd r e r i p1 e ne) c rTi e ah e 0 A nc v oeth gE osfentl t nNN e ieoRa ct oiDF ~
v .
td ) ua h B i d c 3 ,lpAnhft o d d d
t e an N E t oat 5 e e e c r oeFe(l r 0 r r e i ri m B c oest s l ir r u et u nerre e4 u u i
u r q hal ract ursr0 g q q o e t zoomnnsueu2 e e e C r riVf raonddd r r r e un orceeieD n f a nnf u cvcT e e e o gaarsddoooA n n n N orll esnnrrrC o o o N o pP p A a a p p p( N N N N
. L .
h I J k B a s s y e d i l k c r ne e u
h e e c i yy
. an t t t k v a f al na r ic smno d ,t lf oc S ses o iayri bot l m o l N acel sao i f v w ar . ae e O e(oras ruueds1u ny d e F e icpsnnitt sh I h l led eef s t c t
T t s pd nrie5il e l thf e aa n ge C l ead vl0 t nP aat e t .hl hti mwy A noecMdi g2 oc nP i ast p t cosueb i i rso ad n ti oMovme n eneci t E
V at ers nat r sFt lerr ice reg e t
,d,dovd t nhP esixret re rB oo d ucn m ee I noT eocs e slf m e l T
C oc c
S use meeee pn penar indni eek r t s nase rl u
E y.Eds DeeomRd r h o gT i epe ed soit cda u c
eensad d roe e R0 sr) ccso ie n tb h d rv o naiht:h R0 t adNoo ,S ne t vw c os rpes r e O4 C0 nseE rr esc e s iren .aoti o i p pda tT cc us h D
2 mene ecehEevl P pr e .mee eos niesem t
sp l cge enl s l a
eec dti .s d t HNY AR s
g rert Osellemr i ne ewaEsd ou itti gaa co rc ripe rmr geau i .
n ncf st n i ei e u a l c gb b
T ,O n u f seh ot e nt cnuc ne d gd d eea y d M G i qeeahTh eyoc eniooa nse ie n s pk , r fSE r GT d
n eh r rt s t
drso rl r f mnt ed edis iniic g o on rt o cf scwa a es .
HNA CIC i
F st e gt n)l t nF
..st eap oui arn c u a ianer rerp em e eol pisr s a vee ADB h nnesane sg kodt g t e mu ( nct ece b TNU ti emP ueisan cd nind oh g oc ois ren TIS hmuE nmcnwi a a si e ftt n so AF R
gsuc nicokMrf oee-aeiw r l g nkeea rg o e ,i r t d "wine eac t ht a ni g
,O dn SF isl pd odo if rre osuuB en dichen eraTna kvt e cine hr ae iuephee i
E sm hB eqs hi vl t ocm ig m i el at en t e ea - ued D
5 eoec re nT g l e l asi w Rv ,esea rch ud urki n pns .ne eg s esgpnr I
dct sed da Reead c
.e miine.
i ghr 9
,l ern Tpe ts sn l
ann del R a nn in/ l chl esl &
F O so rii e o t efddtPf eei h r ssoa snl ne a
nti o f e s ev 9 gen 1 nhi i t io xi et a
cair insa hi r wodh e
,ewi v
ef h
i Y r en(
R A
usb u dli ole rddl nw P
orrttd ud aoe isozW wns i >m Min g ec ci c
e) daldc ioe h
M nf T wnrvrh eirf aN eea u o eeg ge a ei " egenic T M cac u t c ctl ri o s - r. dc iiti un U ot senet oel al e e S reerah erraho PddaMtl pa ctf T revmo h e T
. 'rfWM poi t t
ep E s evsi h eereer T rd cbrb qa T
h N
h
. . L .
1 J k B a
. g w d
e a ie r l
v i - s l
r e e aa l
e r h . y o da t s ewl r l n n n , vei .
t nn ui og o t o . ii r )
oo cn i
ni s eva .
ic
- t a
et ma c ed eri cem t c
t ay l
t u,c pnr r e ef n ci sa
) cl no e of la pl ,
d ie n m di ,t ocd ag e
u i a ft ow se u c l
a s ni ei n n ru c t e ct nwri
- i t
eq ve ri ev pe o ,
d g op ns inoh eol ned citl n d n h m e vi e o r gi cust ed p C
da n
g nn idt n ece res nt ii de t o gt s
( at o ire n ma rr se m , dane , ,
e N ei k erl h u F isn ec , ot rr N sacd aas s B se f eu L gi an ci ini re ec B nrpetil s yr f on et no ie pung I - l a gf i pa i r a - wtt ebh n 5 ns nut esa u gp aisd cE q n rren , e(
__ 4 ae s fi n nt lee nd el a
5 4
d cti dt ens
_ 0 ns o e na nn 0 n n pd rol 2
ic ge k s u em o igig 2 ggonini t so cuc sk ii - ou a n er rc si t ssecqrt
_ e Dp aao ea er n eereeoe Lcd Pl Do e Dd psrf d
- m m e e l . .
. . l .
E h 1 j k E a
Mf Qe 9 N2 0 -
B 15 I e Vg Ea R P_ s n
o i
t c
A e
v . .- . .
i d d d d d t e e e e e c r r r r r e i i i i r u u u u i
r q q q q u q
o e e e e e C r r r r r e e e e e n n n n n o o o o o N N N N M b
c d
e f
l a k g A
) t y c -
n V s o . n b 8 ee s wA nma o . s s rh n wtdA i
T eVN t ns n x ac a S
N iTL v B at se i t n on o i sr s
eauV ihl T -yh eena sme i otiatittna i
d- ri vtl O er w d ndro o e ahbWb I roe n d it eeo f e re c T ht
,tIio a . i ael ptd y c C l r nm lul mu panf dn nnbhd ceio d A as cet t
a ye nk om i o cuec Al eieea ge w su
.l l crl . evrd wl i d y ot o E ra .u ac V inu hl e isc al uad cacce 0 -
,r
,euei vli p sia evmn
,t nw e
I hdd ca ceenv eh vA co w 5 yn cvm de odmt T
C ecmae t c a
rV r orpol rro t ot neo I iet a eT R el airc t eCt rl h E t orr d a p do dl Ffrh nl R0 ua aiat .
R0 O4 t pf n
robe rgt h
n a y mb s
r nd yno enb ef ve v Caetded 0
st i suaa l rn epecum,o d mhi qo n
C0 eAen e naTf ecsi 2 dV pi y l o an vd 1 rreo e ir nt D- nT rb t w oe c f
of roe ef r eeacrwsm u t a ps ei .ret aic moa 8NY s AR g e ,se p aey ni v
it nn n oi us w sll ssnr ocoaieg d
nee d vorti ngaf T O n enwnc oe he owqes purehmo irmn N
ESE
.G i d
d o i a niwgu d r cm ee ieel e mnt mt ur ergsrur oli MGT n ti rpr i n ( cp r h oii p c e HNA i it enq sa aiE e t t r av cenad mu rog o otf s l v CIC F dl v d ng yui socnndei g f redra ADB nuera en iRexe ef c ded nocn tnt i ogra b q nec r ntit r t np a g mi e if w o usgusca na t ,ri TIS AF ce el ew sr r .
eeyop f r drit ear e nn , sos erhl a ro n eosidru mt eeodd e R s ccc i l oy vtt cdet t s esedd rnd anwe
.O ( yuui ul i r ondsens SF E s b sNn h
qo ef t o at ruueh oq it re nh o a irib x ne yd vtae U pveitC u e e pl n n S
wd eAc r l a f ed v h y q v eeawe ieenV w rOTt e ul d eet gnt rf t esad nt ed S ee cu samra no .oo .
I vi l i l g e r n i
reh n i si n rf )l o i t ve eu er b v ae reoAt irse ysa l ds u , ep F
O R q . h o ae cr ubf etdecnu a wd osre ettf cr d r ennl aoq r) enrn d Y
l a
rn i f a eoe .d e neUb ui u si o oon R
e yd l r po o ct pt n im iqt e . drvctiti ct mbe r o ci ge .seatd eeeeot M innl ot t e w p we rrsam nr ndl ae ck rsnasd ak pairr Eisoauut oc M h a ni c ieh t e t e ump l t n t
S cemav erol e ee hh vi ee A pA nt V pV oe A q e s el ed cqi reh phc asucoegec T acpr V et eh ad u cuooel e T c R n T aT cd T rirt caa A(st dres b c d e f d t n . - n rr e rogea g ee w oninl i d
e t g f n ie d sou s aa v nredc e m eed l d
.r h e vh t ae o d r td oct t er f ee mp fi nn n n d e ri ly oea oo e .
op etf d .-
) inp e f
l a
ne ,r e n d
e
)t rd r iorl al ael vl e
p dsa ee e , t asie e u
n nwu oeq pw nn as ntB d e eo cnt ga
- i t
ci e evd isi v gi s
i gail n) fi sei .
i n
n sea e ti seer 1 t .
C o ( rn i
wr ov nr irend ed o d . ck
- ( sl ie e e v dres0 se5 ur d o s wae v v ep e N ea ru d ous2 nw s
u L iecr ia rh as t ntdse naonsrt o
cs s
B vn . e neid r t eh e l ss sl ds v d o ti I - rcl arn na nnr l ap o 5 l ti el ceo oc eoof a pi e nf ki i i oneR o
- 4 a
ct x v inct h ea t n ah et e or s
- d at siat es 0 ino chl l c nl a wt n ow
- 2 nen ecu c ue I uueise d t
ndK cn t
el lct cqid nm ie n eet ay Al evd oe A v oh a V ad eAil V e e T pa Nt c Cb Tcar(tE
- m T r e
l . . . . .
E b c d e f
B B pq Mf n
me Qc gdc or 0 n t K3 O - isaer e b a I8 D e t S nl s .
I e .il eh Vg Ea . ml ara aeh y RP s n
o rsseo ga h u ..
- oBmt q) i t r a e1 c P nrtS0 gge A eioetN e . . s srmaQ v d d d aeP S i e e e bD ot r r a nti1 t
c i i i r tdo n0 e u u u a ni e u r q q q Datl 1 r e e e abh0 o r r r Rmcac2 C / ai c a e e e Crfgiil eD n n n eorprA I
o o o h repoC N N N TPV af(
)
. N 1 g h.
. Q 1
S a s s l
e r e d . s l v ae o
a r
u ne ih e AAe ef ul s n d ah t t a e s l' VVd glIT a h o -
S t w or ses ,tlf c t m t
r d N ce ie i o acel saoni a inen yd e ne l O ah ft rv i sn e(orasu od c wnb ee htOb e I h ruueds n yi ai rr t u m i oe T
C A
at os r
vt rn ,
eed t spd l
noecMdi p5 oci n r i e 1. i ead vl ld t n rrd ea dGed e o . u- ng f
yner pmi rs o ad m0ti tt ose vi s t ds ne E f o utl iat ers na2 ro rurng . aeueih V i ,lf sl a t nhP esI x ett oopon i st gt t t oari
_ I t el s av noT re et cs . ph pca nl t aaf oc T ncl k l m S use rn en pt a h acsl wo C enac aot c ec E
R0 deue it qh cco n sr)
.Edsmeoeeco y D e e o m pd r ni ui swnrgad t
syna a
n ccsoeieet R0 O4 yet r c inA nV s t adN oo nseE rr ,
SR vwdi e id eli p o s yd e bl o ueit ei
,o C0 esc svn srt amt l pan cTi Ppr reee e uahi e
- D 2 exh g t eti e
t ae mene e .t neeeo iptdh ttt ttl BNY a a s u ecehEevl emr c n t n oan p AR r rd ,e yrs i rertOsel mouo ne ewaesdne i ol l ca ,y nmeees T O n u emt mo N ,G i u n gd b es hi f seh otl qeeahTheEocsi e v e nan oreaoc EGT SE d n
ccani aynd o st nie ehr rt s t
d soas el rwa i e(
ali V a nlfT d pl cs pi e HNA P nmd rh CIC i
f fci y n a o' oeh i nt st e gt n)l t nn
,.stt ap er v rn G nrt go os w P einct ADB aert t h n n e s a n e o s gr e Ne if i e nl be f TMU mtt as , ti emP ueif anep T rv)i N h sno TI S AF e pl e e l lI t u n gsuc hmuE nmcewih aeil rt a IGol I nl a wal Qett e Sv r pP
. P. uman cse nicokMrfl ee rrers af ooN SF O sonn scoo l
aee rm i l od o s pd if ere ,s eeunde ehop O osuu8enra gdt n r h ed E - i i s cer sm hBeqs hiew nn iAu t Ngserem U
S st r ni eoec re nT gv aurrVd no eiae fi u rch ud urki nee h - eGT e dCd eir .
S I
h tt u ids cp ogq wer ne d ct sed d a a nn Reead c
chl e slH s
.ewuos cet t aAbAr rf yso c nE esaf n a l t wh eni em o F.. n ,ee e r ii e o t snl i o p saot rot O g l id y so .h r ssoa ny th n i a Y
unl f ooal ver eeo efddtPf eei r en(
.s e .d e .s rtk ,ett orrttdi shl usa o yvan himl rrt usb u P udaoeh et asg p gt race Mt tt ra ga dliolE rddl nwt o vsnA M aou eel eirf o enuahim cac aN eeau deoiiV
- ri o r f e M nuf q cdu u t c ctl t l r wT dht sil
- U et s n g ot senet oel al a A i pd a Ant nNt p S vifi iye reerah errahoh V hpnry Vii oC om Esod Sb r PddaMtl pactft T waadb Tf wcE nI N
g h Q .
1 S a
_ s .
r d e e sS e l iE l n . l r
g ei p nvgu o r
t u
e eD ieno t o n rN .
el er nn ) n eE) h sadh s b g oo t NmnT arN
- e ic i C oC e E" tt t w - E y
_ )
rSar a" uo ay cl s s
s (l N eC ng ,
.fE d (d p ie g e e s ap ft n smE wn oig .
u wsru ia c ei o
i n engs ru w r ictf nok ce nk .
i i a eq a t vif e ve P t u a(
n ecop r o sgr d d N N nunt s o ri i d a C ati e C nup n r E e aeeg
^
s
( dhe at o gnt bt n e N ncie o d . - nis aa u
ael l sn nl a nuh L t i ea . . ht rgqc s B s nil se v v .
s k yi v yr C ueie o opsd n I - cb e ) o x l a a sr 6. . g oeag ep 4 . ndrd i 5 ndl n ns gp . 0 iep f s ceeK ae na . 2 rs d oe 4 mn/ s a . eot e d ns 0 nrnA h r . t. eiutk 2 gooW ge co n if sT
. ncocc) t srr ic so An d .
. e. igeth eaA fl V
- n e
m e
eeet Dppa er D p V e T v e
m.
le.
E.. .
N nrif Eawaa(
T l .
g .
- Q .
E h 1 * . S a
B ac5 opo8l n
so y /
Mf crf aol s S , ,n1 Uo 2 a6 or2 mt a 13 o3 N1 0u s , g nCe1 r P5 oCd nh n00t2 g e g0 0 i /
N3 N s 4. shi r7 e 0fR niti44 a1 O - Qi N ao k88t I B S e 6 et a8a dnc11 ny S d e eN i a00eb I e 6h , nl 4 shQr r77 m V g E a RP s 0 t 3. heic4 4 o6t oN( aot uLi ntSfe todT88eni 00l t - - pg n 0t -
crn t t aesnOOme t
o 2 Pt lieCCI b i
t sE cdi e o A ffd ult mNN l ))
22 c Dt N leef Ti ti t t cV TP eel s , .l 00 A t ce7 e
Amsf C eeiel8 yecawe00 w h r a m24i p NS i
v rcu o
orrmsA2 d oo V1 t
/bh s t
at ot00 sci 44 N 88Q QP SN d
d t f2 et ctT/ nt nes11S 66 e e c 0c n 5 enset a00 00 r r e P o7 ma 0meema 77 r i r ASr al . t mdt r)88 o 44 u iu r CP p6 rpsdi eii o S 0 0 f 00 q q o N g C e h6N nrnl Ed od nemlpomrCOOf at aomrooCCCf v pT - - 22 DD e
r e r
T0DapaPdcI pcC(NNP TT e e AA n n CC o o
)
(( N N 2
a b c
, s n s f ss t n m i n
ol e i o r o or se f l / o .s i 5
l ru Ns go r t e f t , s otd C nn e ac n e . s 2 rne E eil h cn l e h i C t oc cso t ia i m T e. s m I nco liir o yf i ct es ii o T o r l l vt bir Piari (
C cep . a en d da Efhi . )d A v d gro y E
eiee f n c iedoV em Oit us qs c l n1 n o a V ivt aui rn oif t or f s i st a l eemee h porc nei6 I t rs a sa e oht - s T ct ot urst t enu t sr o t aP r C esl n t est nren fl r s zE o edra ap R sin r E
R0 fi ci f n a apee dd rm lef odn CI n( r t ocb i au eoe D a e C4 0 ei p m mo s
grh o
hw ct".
ct lhf wf ott vih s gs fR rN p C0 td od nnps ceeeu 2 aAl n ioivel i . nhjp ,ori pdd oC oCe D E e D h a N ih t on tk md n w g k 5NY s t tihbQ w5 ri AR g .dnd aet aS 1 yp acI aa h e ef ng i oind T O n , Nae t c t n b n thsf , v til N ,G i ry t nenst oN P g caos enaru ESE d eS , n eriea iCdEi d h e roneo MGT n v se m tE nQs er iivw t NA DIC i
f et em was sle eesos a aS e ler ossu nt go l cl t n A 8 o pn o m rh e ., e "D iff eae sud i aic ,
TGU TIS hd ep ecm ImiAsi ot1 h rsccc d noee t r d
- e. opr ee sV et f t ,
rw AF
,M
,noi di r e2 T ra uc '
n y6 ib - y 2 e vrrte ap o v meuo eapy l uhdl SF t
gt l h
tt nef
.di Pb3 mu e oct el E d nee i oci edE geNdP
- a qN ct esc ac v o co U eirt gniod ndf of S
at eE t El e i orpf S
l aua wms oqu inUt i pmro pcorN n pj d o wNd eti nie o sny i I
ntl e eQdPt rf ef2 qt uo oah nr i at e .
i tti p ihd m F k ocd i SaE n va e t n gnl T nu O cn a v Qa o t rs ao ,yt noi am a ,
et nSl csn n iib Y
R sano s gt raI d
p t eao lucsl nsee s . rti . en i
N nmli at out t eas)tl M awin h t 15de . ne ar C eh rs E mcen voioaa entil u ernRaa U
M AN ar sce u)
A sLEt u
ecti p uat a sv q inaoP pp uqa S VC re V SON u edeeee gesCe
~ TEt w h ot rx hi urhd nreUd o Ti(Df TdAcE Tdqpt a E prNat b c s
s t d t s e n r g e .
t e e- n uy a m . rfi ql n us cN ",dnp aae er i
b rep im edEoCt s aen raa ,
,' eo
)
l g inp e gr d e a r yl o nr np e pebkiNi a a u n h ctC hd n ortd eaEtt ce eoeh r l n t i
isv t ceeua nn vcoe" t
n i of c dh sl ge o e f ss it ep r
im s u C
( rt nfi ny r noah ob yo ec s d o e N l oi t c a d u l rt s nmt f Q f aafd o n s S ot s P ceoei ,e o i - E ei r rt rm yn Onf a ni c e u . t 6 ti oua wcd ie e t ti q eoe rr 4 rnnnt eeidk oa 0 d uoeaarvv o j 2 dl n i ed o a) e e i pi h t rel cc mci t r ms t R n oardii sdce eC e rponl nonev hD m P sf aE wpaf o T(
le . .
E b c I
B u Hf m J e d a G e r 2 c g N3 ot odd O - rnrnnl IB papaae l
S I e dP) e)f Vg n P nP Ea aeHiVI RP s hPlB n st(
s eDt o erea s(i i
t cogB mU) c of a A r k nre pd c g g r e
v .
eaiooN e pP srfB i e e d t o eP t v v e il sD c o o r sen e b b voeod0 r a a iu eeiht e r q hdt tt t4 o 1 t a
~
C 1
e ecf C e a a r Nbi ol m B f e e e n Wli tff id r r pA e e o tl oaemC S S N A w M pV I(
N
. 8 .
d e f W a ye r .
fd o e t p io . r oew f . s t s h e d N C a l ceo esi d e C U u S e .i i s gf l civ es u E N . t t q N h r rb n e al nl e eNd s ne t a $ e O t ee iae anh , aab r nC n sff gd n p h d I e rpnt e gh ot y e ua E a .i o oi u e e td a T goaoenh rnci d ost o d s C nt pceat ea st l
ut e .dt syrecw sl e c ee A a eswl th el n gn t
isst n gnrt l e i enNt ed nt o niuo E
ht r cf pee t pnach we ie t om nne cd ,
f cmeCib s i edc as n V - e gbd rn re ii rt neesr rrcit rao i t rmEl r e t eou auh s b n aeg idt o I
T fl en h asat n s g g n pl p meue eeCj) of uoht c
n ,f cf untt e e rooq iinnl cr e C ie sth n nes ii f m n ns ,a f a
,ew E ri lbi osrePe d sed eoea gk m cosed ed oi rN bP r I R p e e gt mh nc e g R0 b f i emide og .PCs Ni C nmh r e pi a h nns R0 ronsnev vet rns Ei e D eD egut asv rp t eie O4 ee gsi voel ca penP( rh m ,bil l eok e ek r C0 hveiul orronh oE huae o son grree sb cu 2 t o c s c p r pi v e t t niQsct yt ssoevoanpong e D cnesi p t nd ad s a sits eiaoi Rtd amwin ga t t re BnY cdicedniis . ah 4 gh n u S oC et mhi aot c AR g a
l Ni dsll e u
vem pt 2 enwgq tF srh coc nnh i n o T O C re eereut i1 h a ey N
ESE
,G l d
dEetli e pea ddoen awnth ,i a ca sSt u .
e ,i et ar h pfd ei d gec t nssp
,r MGT n d exl mdt stl ney enhiods gsgy id e pl s sttl m nR a o oi gs negg ensnn aal HNA i uheprea p cs th oe CIC F l t mot ct ei d o inerb go nrnh geatDv ea oCh r noadii s rr pNt rt e i pl ss b st u AD5 c dof ciat cnrl vn dit o s onvt opgee uN ns TNU nnncnedhasupo aanesit ,er esk oil r ndd sC oo TI S ioa if nt cio r hh et e r n yh p rarsct upei E cl AF e fi idf nt ceaDCel t p og as s rde e c R l ent l
dth na mn in d wt a inhwnt geyeunh SF
,O ad e o
eat seugm nanc o ent c nmlay c i oerbhd unwnn at sf e aovp E
U ti evgont mfthhsmieo yorti n ggei . oonbl dibdsl co es et idn a d sga e i rsyre kd T
s ,f gno b
aoal i o l t o S d od e Asce t g l edsrart ei resdenoc . no trr S rundmV enai wd niucoirf age oawusi in I f pjonoT eynocs o a at td dif di pnd nd d st t o dns n o rgt pf ier gliii e ng nef dar ea o ,neeeci oia f nl gt nd kcieiode nsocisAho rne gnorceut Qcn O t onae .aanau cf pchdnoi omra A i ,
Y R
nficdsl h ut ri opef yen recr meumtn ohaoe l
at nt ron snl n aia pMi .
l NBN
,s en r gl t eiit er aeiu t rt cb pt sn nne tt Cems vd e i r mieil ennf cvcn a i pi l npCCC NiAs arntt nognae a aioeed rd eeom Bt s m1 c i n a i s ii e h m hdid a gi E C E rcruic srnndtl guce Wce e W
S esgeegrs h end rneeoonue ecr A o s o n s s e el setii asunq Ndnl g noa e ,lp ef N o
.c TdeI g e pd t t T sp V o i o a ei h h l C oennohh rR m hfB r T cdcMDdt t a E acdEI cscfPi T eW p N
d e
. B .
f W a s n n s o e o s c r g st s g a i
t t
c el e nuh rgn in na eni ) , k gc e)i st di s srd c ii .
f ml e nyu N en a sfd f rprf aa ,- C na r eie eei o ihle c E n
) ddi t cs e - si n sdd (aM .t d of h gi h o N n s mC nen e d mi t t ndTi . C ya ey E wt a u n o t s Eb oah n arn ell ae s icl eok qf n i oe t l . ug fk e t m e t efd a ranl n ori oi s gd g n p oaa C
o odi cey ino d
hi vh rwi ot Nt unai nti
( srl t t ec e v euaef e s r ric bfi g tb od
_ e N gut ie oa wuen oe mot nns u Q rt g u c N aa nk) s S inqa eu cnst ai
( esus nya S h rgcA s rrq t gnqe t W C neiaV ,
i - e e ein ipslT) ognoed vl o - g oe esd nnacd iai 6 nea i h af
. nt rd a s ut k 6 up 4
ii gtt s eo mceno s qcr iro d s 0 nio ti e uo 4 e t eiD 2 evn ocni dpgsnc t cerw 0 ed ut xht e 2 neoceN .
aa t
n eti e h cr A
ui sd p et sr t
i sh erE g got f e e T aa V f ennm n n nl i f hf T od ai i A e E cwaT o(
m m e e l . . . l .
E d e f E a
B Mf Uo N
3 N3 O -
IB S
I e V g .
E a e RP s v n o o b '
i a t
c .
A e 2".
v e o a v . . b "
i d d a t e e N c r r Q e i i "a S r u u "
r q q e o e e N e C r r B s W
e e o n n e s o o e l N N S A b c d e C t r 2 d C n e e a90 e e Me ig th "s e e 2 b s
u ,ta a
s s o ge nt eh 3 t S N ys re4 l es e .uo e .i e innn N E " d es l hi h qt h r d e e a o O rnh eP it T e. e t ee ghh rrm d w s i d s e rpnt sencT oerd I
T e fov eat ,InE*. - ni ( an goaoent raa f eee
_ C t os P o ei . o nt pceaiohe nps A
d a ecny s ol .EB n s nsi t y l e oi s nsi a ht r eswl t pn mc .ni oeogeb a
E I
V t1 u1 oCt o
nNit1. n pE ae6f o W"r on pon si e nhi ott)i a1 m s cf pee fl en e gbd iaet gi nh nset eal h nset e b
T f s rr - o et h sez o e h asatd ph wnt C eoeeerP raw Rri6 isthn nigocoenl E
R0 h
tt rhd tiCN u E A "s e eem r C an D aP n d
b ri f
cosevnc i e m oi s e p w m i reel R0 se s tn y ii vd ar s gE a ronsnert h t ew O4 fRrN ee g si v p s e t f el C0 2
divmn eli oo t rcl
. foe" mf t sg i no oCo(s D r h v ei ul o t ocscprounn eg ob ph mc BHY D
s inaif a s 8 -
i2h o c
sor ocp w
ef cNr gso n
c n e si pt qaieeii edicm eh cp n AR g pd o d 2 P t ae p i oiC r iNi dsidrcd noow T O n mepe E nt s f) v tE e C re i e eect N ,G i on voOet n aoP ena dE etldddpnvd e n u gli s em ,
ESE MGT d
n cid ot caem oh mao p ttP M rongp ii nie e
duh exl pea mdt eoiovere H N r. i at redt cns as( nt gt e epreat rsvegut CIC F aire aoe hi i ai r k l t mot cngen nd s ADB t ou d2t r tll t re c dof cii di oaey TNU acqsn t o o d novd nnncned e nh cs TIS h eaatAse nrr ee ol i oa If neh ee co AF R
t2 rwpn l v iioat n vmecu o e fi rt rnd rl
.SF
,O t e4 as 5.t t emo x enai h ei t tl o amc l uh oct ew vo r ldthna l ent o ad e s
a ii nepo rtl u'h eat onpot st r
E e hiscsrs ici indfoddu , ti mft hhaf eif t n U hdtl aanao se g evgont h c fi o 5 sn wt o p d d snycw ee dod e At sesmo c 5 ass ti s nan a rund mV nhi a n 1 r nidAt na i i at oo f pjonoTmatd enie e2 oh n ao rh i rl o ier ee t g F asrie ooc gnl pl n gt pf meg io sn O v o
c4 a
- 0. i T t
l aet r d ai nf t
noi iibef o t onae niicdsl y e ai o a n h
.ts t nnt ea Y
R A
H s re ". -l eseq CPd oPd nd e di ru sdn .
ieeN rnB rtih easTf m ern iu
. ut ri opef yen mieil enet neanpn r e s v c ri ci c iietil H EEi nE uoir eiaW nao m arntt nogcunuuig N
U eS n
- s" Ol cs c nd rum eqrr ipp . ,i ges)dn cinaisnemil sci esgeegraf mganssP S hE ornn9 on neeo nreRnl h end rnehf onvoieH TDcoii2 ca I r pf E prP aa Td eI gepceceecddP b c d
_ s
- d t .
- e n r d t e e d e a
n m.
us r
a e
naf
- i cN",dnp a - n t
gci im- oCt aene e ii t i
l g edE s inp rar a
em gu sf n ei e
) e a r yl o n nc ddd d pebkiNit ao oi e n h ctC n hd dm u ortdeaEt a C n y n i eoeh r ll t arl i
t sv t ceeup no gn oe i
of c eft n
o vcoe" e f ss idns t er ro i
se p
od u a
C rt nfi ny er ceq
. ( noah ob yt . Da sr e s l oi t c and id
- e u B M irt s
- f aafd o nmeemk f) os gua nq s W P ceoei , uo R et I
s E eir Ohf aniceol rt rco tD yC irro e n ti oua wd r i( es 6 e t ti q e e r . nee rnnnt eeid v osy r 4 uoeaarv veo jtl iigt a 0 d dl n i et asr ni 2 eeI pi h t rcg cc mci en mee up evs i n
_ t oardii sdfi eqo et o
_ n rponl nonf e ner h ci e Psf aE wpaab IR p T aL m
e l . . .
E b c d
2
- s s d e R2 e 1 , g n 1I E4 c e sP g eb nnI B o u t n t
i g 0 Mf r senPi an. ti)2 Uo p sd eEt re4 nsP -
V N i iv m oh 4 )
eov eB Fe gr n n pt6 aeV 6 rDt8 N3 P g O- Hen bronusclmiolP e8 I8 S Phoo price p iN E e h (0PI ht mdd odsw I e (t tl Vg 3 a t m,.
lI e 3n d ya1 Ea e e0 4. wl i oois pf ng e0 I
. gc- a ebrRR s e ao66 ol - c g n v klB l ndo44 -
o o cs 7 resl e63 i er12 i
t b
a e v
a pNPN2IP/neor E8t vdot h8 6 I smP r A c ,
- b o F nBPd 1 c odht t nn gP E don efo 88 .
e 2 a o P uriI e e v o
i tFa E n d ef mctE f e oiP N set I v v b a
e
. t aB e gP nF e spaPP o i " 2". a t n i b a v gicPd)
- 3. naeenmddeBc t cef E n 1 a c N o a" c o6 m e h h v a e en snf Fa0 e ct or
. i e
- "a Q d b f a Nii6 r
r
- S e r
a M
i do p l
nPl oE n g p g,lmef pse.rCerEbeh0,N 2".
o e mnt iNaiipgnmnire N
i "a Q VtRB F a C B e u q S ii ur fe i "
s " l st W ia tdd ordw16 w aae n 2 e e nnn7 .ddrteahaneo t t N o r N e 0 Q e s B n gi t ra ct eL e e8 a rete w s s or d e s S S
l e n
W l a em/ i v Oen80 c64 A o e o pb e 6 7 h n 3 n giepe na e N e s espl1 //r8ti0inei s eeidI2 e e
. S l
A ham 69 - madv rhl t eo rPD s
N Thi00fb8au y6 dcwr h i e ehfacl sc ,I A s o
f g
F B
. ToB a A (C l A
a g fB r n oCs s o S i l CN r f N t a
, l e C en eg d N
e t
I O
n yl n a nh ceE ni d es e l ,d tF t a T i l
agoatl ri s u l net aB a C d tnns uit u age eNd s iot n h eu d A l ol nd nCn s wiae tt rq e rneaedssshanue g d Ea .i s ,ti r g a sd ue u s
V E oero e r Mt D leiie w d el re e
.dt s duiu ct r ndoa Pnss E gi i I cwutauebiunreu i fcmeC enN ernc tti i el dnct Fi T he tCc e e r o t e f nloravoyeu vt i t rmE ns f ni o BsAs)L C tb jd t eou enNo ia ,n eV N E
R0 i
wd) rli ousee fsr a m es f n e .fcf moC ft g ddTC n (O R0 b l t car ns idsed roo e cE l s
u eiir nne ar .E e O4 C0 man e n. P nnel c e oi u Rp e pdft hake enl s D
2 l s 5PicriE
,tfl ps c eDegu nm C ml oa ie i t .
t mcw a Evol Noiae n 8NY 's be 8 i ht u w r n nii m,biso o l yfo nsre enrs D t c w a ooocd taeet e lifi f AR g o n A.eC ri WN )s P t ioi s ssoev l inv ,r s o d ol N ,GO n ,nPctti pl l trd u htoo lb ESE i
oCRtd e gai n t sd u it asg MGT d n ai pt(n s WipphEtiBruegNeacdt tFsrh f utt r cnac ntl e aooc n un HNA i g sc (A ysmdeDaiep e l rns e,iet nrett t goat n cl at i
CIC F ni sst h ehmn s nro r i ADf TMU t
idt v beunheevdeu gcatt rtwro nRaoo r tl hteee w bs t.
uaorp i sr .sr e
t a al sdno oCh npeomr vtenp e T l AF IS hl aeadt i eoeg spNt rt shce reuiroo
,S h ,oml f et R a ptha ny Ts b s esk ono miipe Ps , u r
SF
,O d et cael inlt y esn
. r go rars c at mb Ptiss bttr E
U ehhcnrnau gtti di ditgeonpl uni nhwntio og rayi gll oteee d NCeo FEsl B
f ohft s uai e
S ewnis dit ic sc sieetnh S l ws si errt coeaet iDv ooei cec a dsga unw n rt pniTf mhi eocp fe sl h m i e irs it i h oo ebt eg ca F oes iDCoierrmf fdhpp aresdege f me r tl o pl ro ot n pi l n gn n . on s pndnd o Po r s. e f
O kn noo cai Adt p nd i
ea rue v dr nt ed rsimv pe ii y afoo o g dfsge i
Y aht sie oimt rhe anvn N e R
s ca arai tet n bl pchdn e nnb oia e oF e c M ani znucl Ndncntaeae. en t ei ssea oN sct t
htBhe t
U M hg i an d e fiE r fi di pC edsg ei n ii e s r gl ae t r pCl cl oEl hl r e ras, aeage st t r S rcic aioee r inw i ovts se Asgoodsearioca V
eroroinhov onh n CNdnl TdocpMdt i
dr seti sr nn g
i pk v g c i s pi eti s rcne l usin sdewi r nc
. cfe ca c oen eadsN eic ieges c EacdE hrneC T t adE Af mo Vfdr AoavN cni f
. N TeAp TVrneF pcrB g F .
B a s s t st c el e e)i nuh s r
g n
f ml est f rprf d e i s 8 eei o ngu 7 . ) .
) e t cs i na 9 5 s f
)
d sin hic 1 8 N o s
e u
h t
o gi h o .
ndTi sad Nl n y
i nn1 e
9
(
C E _
,' k C E
N n ell t s Cea er cS i t ae aE ,
t n no a r a n.lun g l
Ed s
fbe f b st eu l D .
g o oaa f ye otoem cof ongs aNEe i
C
( d - hivh obi t dnv i
td s rricttec rki e o e
u N B
oawuen oe rt g erv boi neN gv oesi Nsus ot ir os
(
s W cnst ai mwt iaf el eef e s
t
(
esus u c sho gct adr egn g I
- gnqe nf a n ognoed o egs N ay sdhna 6 nna cd e n vyo rna F B hl rt eTih i h ei k c )
4 0
smceno eo ocni ti af i ti sit wrd ee -
C eec rpe guof nrg .an c 7 8
2 dpgsnc t sl c t et ann nt rf wtis /
eau , 6 iapao 5 t
n A ui sd aa curk xqt r hie t gm 4 rm nee 1
/
V f e p e 0 eetdkt erun a odainne e so ne d 0 m
e T
l nhoe enw N sEl p
2 i npoagu) h (
1 l
At cr C ym t get nqA
[bi n nriCNieV E e e edT 5 f
m e
EawEba( 1 g l
. D E a 9 9
B P b r onuscl E eh(P Mf Hen price iN ht Uc Ph oo p odsw t m N (t tl mdd a d yaI 4 3 l ie g 3 n eb rRg N3 c O -
IB e
gc e - 0 4. wl i pf n e0 a oois - ndo44 a n66 ol l e63 i er12 S ki8 7 resl h8 smP -
I e cs E8t vdot 6 r Vg . . a IP/ neor 1 d on8 Ia e e pNPM2 odht gP E ef o LP s v v F 1 c t nn P uriII n o o nBPd eoiPM i
o b a b a
o E nd i tF a e gP efmctE l
nF e i setPP spa c
t t aB t n ddeBc gi c . " . a 3 naeenm n A e 2 e 2" snf F v v cef ehh vae e NiiB e o a i co6 mct o ,lpse .r C er o a e r Eb ehO v b " . b " if a l nPl ngpgmef V i a d a d poE pgnmnire f e t N e N o i N miiii ur ord c "a Q r Q mnt ist tdd an e S i "a S ia eahaneo w a r " u " t t .ddrt ract eL r e q e nnn7 n gi t o iOen80 o N e e N e aee8 arewssrd v n C B s r B s l em/ et iepe eeidI W W pb e67 h n3 ng s rhl r o e o l1 8ti0insi t eo e s n e s esp // r e s e l o e l h am69 u y6 d -h maI l' v e hf ac S A N S A Thi00fb8acwr T oB N
e F f g B a
, r . . t fB s o N e a g oCs r f .
n en tF t l CN d l ,d aB a d i l e C eg d e l net h eu e S t ,
aceE ni es u i ot n tt rq u C a yl n nh ris eNd s wiee aue s C n l agoatl age nC n s ,tt r g sd P nss i
t uit u l ol nd E a .i ct r I
T d nns shanue e
d s d uiu indoa el E gi i .
Fi )
C A
rneaedss o e r M D teii w d el r g e
.dtenN s ernc d nct o
BsAsL i t ti eVNO oer l enreu f cmeC ns f ini a ,n ddTC(
E cwut auebi u vt it rmE enNo ft g n V tC c oravoyeu t eou moC nne ar .E e I h e eerot ef nl f n f cf ecE s eiir enl s T tb jd f sr a e . roo l u h ak e E vol n C i
.ousee m es d sed pdft t mcw Noiae E wd) rlib oarns iRp e iml oa a D t c R0 man n. P nnel c l t eoiu C nm ie t
. enrs li fi R0 O4 e ,tfl ps c eDegu nsr t et e sod ol 5Picri m ,bil yfo e ae r t rd C0 o so ihtuwrnnii l s l inv ib ,u it asg 2 b e .E B) ooocd ssoev l ht oo t sd n un D o n A W s w a P tii s Rtd ugain ntl e gonti 8NY s ri N ctti o oC e aooc AR g pl .eC ,nP gN e a c d t tF srh f utt r onau t nro i ncI at t a T O n pphEtiB rue
,i et arett s t r sr N ,G i aipt( nsWil rns e h eh mn b snp isr e . e ESE d cA e Daiep ssttl ht eee uao vt enp t GT n gs( ysmde vdeu nRaoo w npeo l mr sh ce et roo HNA i ni beunh ee wo oCh r
,u r reui CIC F idt gcatt rt r pNt rt ,oiel f P s btt r ADB I: U v
al sdno aeadt ieoeg
,S h b s
esk on o
mil pe at mb P Nss NC eo f
ohft e uai TIS hl pt h ny T s s rarsc rayI FE sl s nh AF a acael y esn og gll d B sc sieet R d et nl t rgo nhwnt oteee f e sl h m SF
,O ehh cnri n au . uni r ic unwn io rt mhl eocp ebt eg E
gtti geonpl dit di dit coeaet a dsga pniTf i t h oo ca l n t tl ro ot n pi U
S ewniserrt si iDvcec e i rs P
.re o pl rsimv Hme S
I lws oes iD C oi e r r m f fdh pp oo i l
resde age pnd nd o P orsv rue dr nt ed anvn pe ii eof ec N e ngnn n dt p nd ea o df sge oia htBh e F k noo .osA af oo rhe g e nnb sct t t r O caiisie y oim pchd n ssea t a , st Y
aht t et n caarai .blaeaet . en t ei oN hl rers ineage t s znucl Nd ncnt s r gl ae t r pCl cl ovt e r nc M oEl i pi ss usin M
ani i d i pC e i n ii e aioee srnn r
iwg nw eti s sdewi h h iga nrcic d e fi Eirf d r edsg n setii pk c i s rcne i eges eic cni U Asgoodsearioda Nd nl g eadsN Af mo Aoa vN S V eroroihh ovonh C oen h rneC Vfd r V rh eF YdocpMdt cf ecac E acdE T t adE T eA p T pcrB N
e F .
f g B a s
s st s g t el e r n .
c nuh e i 8 ) )
e)i st d s 7 . s f s f ml e ngu 9 5 N o N f rprf na 1 8 C C eei t cs o ihic y nn1