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NUCLEAR REGULATORY COMMISSION WASHINGTON, D.C. 20066-0001 o% ...../                                   August 26, 1998 MEMORANDUM TO:               Linda Kilgore Public Document Room LL-6 7
UNITED STATES g
FROM:                         Glenn M. Tracy, Chief               ''I/M Regional Operations and rogram Management Section, OEDO
j NUCLEAR REGULATORY COMMISSION f
WASHINGTON, D.C. 20066-0001 o%...../
August 26, 1998 MEMORANDUM TO:
Linda Kilgore Public Document Room LL-6 7
FROM:
Glenn M. Tracy, Chief
''I/M Regional Operations and rogram Management Section, OEDO


==SUBJECT:==
==SUBJECT:==
==SUMMARY==
==SUMMARY==
OF THE NRC SENIOR MANAGEMENT MEETING JULY 14-15,1998 Attached for public release is information regarding the NRC Senior Management Meeting held July 14-15,1998. Attachment 1 is a summary of the January 1998 NRC Senior Management Meeting. The Watch List Removal Evaluation factors are provided in Attachment 2.
OF THE NRC SENIOR MANAGEMENT MEETING JULY 14-15,1998 Attached for public release is information regarding the NRC Senior Management Meeting held July 14-15,1998. Attachment 1 is a summary of the January 1998 NRC Senior Management Meeting. The Watch List Removal Evaluation factors are provided in Attachment 2.
Attachments: as stated cc:       Document Control Desk OPA EDO R/F pr o3 o h9//.
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,                    ATTACHMENT 1 t
ATTACHMENT 1 t
i         NRC Senior Management Meeting Summary July 14 and 15,1998 Region ill l
i NRC Senior Management Meeting Summary July 14 and 15,1998 Region ill l
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l       ,                                                                                                                  I Following the June 1985 loss of feedwater event at Davis-Besse, one resulting NRC action was
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              - that senior NRC managers periodically meet to discuss the plants of greatest concem to the               {   '
Following the June 1985 loss of feedwater event at Davis-Besse, one resulting NRC action was
agency and to plan a coordinated course of action. The NRC senior managers held their twenty-fifth such meeting in Region lli on July 14-15,1998. The previous meeting was held in           ;
- that senior NRC managers periodically meet to discuss the plants of greatest concem to the
Region 11 in January 1998. This most recent meeting was structured to review the status of the       .
{
Watch List plants identified at the last meeting and to review the performance of other plants to   -
agency and to plan a coordinated course of action. The NRC senior managers held their twenty-fifth such meeting in Region lli on July 14-15,1998. The previous meeting was held in Region 11 in January 1998. This most recent meeting was structured to review the status of the Watch List plants identified at the last meeting and to review the performance of other plants to determine if any changes should be made to the list of facilities which require close monitoring l
determine if any changes should be made to the list of facilities which require close monitoring l                   by NRC.
by NRC.
In preparation for the meeting, NRR and NMSS, in conjunction with the four regional offices, AEOD, OE,01, and RES, prepared background documents on the plants and materials licensees to be discussed. Inputs for each operating reactor plant included a summary of the most recent SALP and SALP history, a discussion of current operating experience and licensee performance, current NRC and licensee activities, performance indicator data, risk insights, and     !
In preparation for the meeting, NRR and NMSS, in conjunction with the four regional offices, AEOD, OE,01, and RES, prepared background documents on the plants and materials licensees to be discussed. Inputs for each operating reactor plant included a summary of the most recent SALP and SALP history, a discussion of current operating experience and licensee performance, current NRC and licensee activities, performance indicator data, risk insights, and enforcement, allegation, and investigation information. Data pertaining to safety significant hardware issues at the plants were also provided. Inputs for materials licensees included a summary of recent performance and activities, including significant areas needing improvement and potential chal!enges to future performance. To enhance the application of information
enforcement, allegation, and investigation information. Data pertaining to safety significant hardware issues at the plants were also provided. Inputs for materials licensees included a summary of recent performance and activities, including significant areas needing improvement and potential chal!enges to future performance. To enhance the application of information
- summaries, pro / con charts and Watch List removal matrices were developed. This information was distributed to meeting attendees prior to the meeting. It provided the basis for review and f
              - summaries, pro / con charts and Watch List removal matrices were developed. This information was distributed to meeting attendees prior to the meeting. It provided the basis for review and     f   '
discussion of each plant's or facility's performance and for senior management identification of -
discussion of each plant's or facility's performance and for senior management identification of -
those plants and facilities warranting increased NRC attention.
those plants and facilities warranting increased NRC attention.
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Cateaorv 2. Plants authorized to operate that the NRC will monitor closely. Plants in this category have been identified as having weaknesses that warrant increased NRC attention from both headquarters and the regional office. A plant will remain in this category until the licensee demonstrates a period of improved performance.
Cateaorv 2. Plants authorized to operate that the NRC will monitor closely. Plants in this category have been identified as having weaknesses that warrant increased NRC attention from both headquarters and the regional office. A plant will remain in this category until the licensee demonstrates a period of improved performance.
Cateaorv 3. Shutdown plants requiring NRC authorization to operate and which the NRC will monitor closely. Plants in this category have been identified as having significant weaknesses
Cateaorv 3. Shutdown plants requiring NRC authorization to operate and which the NRC will monitor closely. Plants in this category have been identified as having significant weaknesses
              . that warrant maintaining the plant in a shutdown condition until the licensee can demonstrate to the NRC that adequate programs have been established and implemented to ensure substantial improvement. The Commission must approve restart of a plant in Category 3 status.
. that warrant maintaining the plant in a shutdown condition until the licensee can demonstrate to the NRC that adequate programs have been established and implemented to ensure substantial improvement. The Commission must approve restart of a plant in Category 3 status.
In addition, plants may be issued a trending letter that formally communicates NRC                       I management's concems regarding adverse performance trends. This action is taken to inform licensee management that plant performance, if not corrected, may result in the plant being placed on the Watch List at a future SMM. Finally, senior managers also consider whether plants that have demonstrated superior safety performance will be formally recognized.
In addition, plants may be issued a trending letter that formally communicates NRC I
management's concems regarding adverse performance trends. This action is taken to inform licensee management that plant performance, if not corrected, may result in the plant being placed on the Watch List at a future SMM. Finally, senior managers also consider whether plants that have demonstrated superior safety performance will be formally recognized.
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(                               NRC senior management will transition to an annual SMM schedule as directed in the SRM l
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NRC senior management will transition to an annual SMM schedule as directed in the SRM l
associated with SECY 98-045, though the ongoing review of the NRC's performance assessment process may result in a revised process in the near future. Recomrnendations will be made during those meetings to add or delete licensees from the list of facilities requiring increased agency-wide attention based on demonstrated performance. This program -
associated with SECY 98-045, though the ongoing review of the NRC's performance assessment process may result in a revised process in the near future. Recomrnendations will be made during those meetings to add or delete licensees from the list of facilities requiring increased agency-wide attention based on demonstrated performance. This program -
represents an effort by the NRC senior management to focus agency-wide resources on those plants and issues that need to be addressed, to communicate the concems cf senior NRC managers to licensees with poor performance or adverse performance trends, and to ensure that coordinated courses of action are developed and implemented for licensees of concern
represents an effort by the NRC senior management to focus agency-wide resources on those plants and issues that need to be addressed, to communicate the concems cf senior NRC managers to licensees with poor performance or adverse performance trends, and to ensure that coordinated courses of action are developed and implemented for licensees of concern before problems reveal themselves as significant events.
!-                            before problems reveal themselves as significant events.
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3 Summarv of Decisions L       The following enarts list conclusions reached by the senior managers at this meeting and from the previous meeting for nuclear power plants and for materials licensees:
3 Summarv of Decisions L
The following enarts list conclusions reached by the senior managers at this meeting and from the previous meeting for nuclear power plants and for materials licensees:
NUCLEAR POWER PLANTS -
NUCLEAR POWER PLANTS -
;        Meeting Dates           . Cateoorv 3                       Cateoorv 22                     Categorv 1                   Trendino Letter JULY 14-15,1998           Millstone                         Millstone 3                     Crystal River 3             Quad Cities 1&2*
Meeting Dates
1&2'                             Clinton                         Salem 1&2                   D.C. Cook j                                                                   LaSalle 1&2                     Dresden 2&3 JAN 6-7,1998             Millstone                         Clinton                                                       Quad Cities 1&2 l                                 1,2,& 3                           Crystal River 3 i                                                                   Dresden 2&38 LaSalle 1&2 Salem 1&2 Zion 1&2
. Cateoorv 3 Cateoorv 22 Categorv 1 Trendino Letter JULY 14-15,1998 Millstone Millstone 3 Crystal River 3 Quad Cities 1&2*
!        (1) In July 1998, the senior managers did not review considerations for decreasing or maintaining L
1&2' Clinton Salem 1&2 D.C. Cook j
the level of agency attention at Millstone Units 1&2, given their Category 3 standing. On July 21, 1998, Northeast Nuclear. Energy Company. submitted a letter stating their decision to cease operations at Millstone Unit 1. In an SRM dated July 22,1998, the Commission directed the staff to no longer list Millstone Unit 1 as a Category 3 facility,
LaSalle 1&2 Dresden 2&3 JAN 6-7,1998 Millstone Clinton Quad Cities 1&2 l
,        (2) in January 1998, Commonwealth Edison decided to cease operation of Zion 1&2. The licensee is no longer authorized to operate the facility. As a result, in July 1998, the senior l-managers concluded that Zion 1&2 should no longer be listed as a Category 2 facility.
1,2,& 3 Crystal River 3 i
l       (3) In January 1998, the senior managers concluded that Dresden 2&3 met all the Watch List removal matrix items except for corporate management oversight and involvement in plant operations.
Dresden 2&38 LaSalle 1&2 Salem 1&2 Zion 1&2 (1) In July 1998, the senior managers did not review considerations for decreasing or maintaining L
the level of agency attention at Millstone Units 1&2, given their Category 3 standing. On July 21, 1998, Northeast Nuclear. Energy Company. submitted a letter stating their decision to cease operations at Millstone Unit 1. In an SRM dated July 22,1998, the Commission directed the staff to no longer list Millstone Unit 1 as a Category 3 facility, (2) in January 1998, Commonwealth Edison decided to cease operation of Zion 1&2. The l-licensee is no longer authorized to operate the facility. As a result, in July 1998, the senior managers concluded that Zion 1&2 should no longer be listed as a Category 2 facility.
l (3) In January 1998, the senior managers concluded that Dresden 2&3 met all the Watch List removal matrix items except for corporate management oversight and involvement in plant operations.
L' (4) In July 1998, the senior managers could not conclude that the adverse performance trend had been arrested at Quad Cities due to the limited operational data since the last SMM.
L' (4) In July 1998, the senior managers could not conclude that the adverse performance trend had been arrested at Quad Cities due to the limited operational data since the last SMM.
MATERIAL LICENSEES r-      Meeting Dates                                             Facilities for Priority Attention
MATERIAL LICENSEES Meeting Dates Facilities for Priority Attention r-
      ' JULY 14-15,1998                                                     None JAN 6-7,1998                                                       None l
' JULY 14-15,1998 None JAN 6-7,1998 None l


e-4 Qincussion of Commonwealth Edison System-Wide Performance COMMONWEALTH EDISON           .
e-4 Qincussion of Commonwealth Edison System-Wide Performance COMMONWEALTH EDISON The senior managers discussed the system-wide performance of Commonwealth Edison l ~'
,        The senior managers discussed the system-wide performance of Commonwealth Edison l ~'       (Comed) as well as the individual performance at three of its nuclear facilities, specifically l         LaSalle, Dresden, and Quad Cities.
(Comed) as well as the individual performance at three of its nuclear facilities, specifically l
        - The senior managers recalled discussions from the January 1997, June 1997, and January 1998 SMMs during which they recognized that while the SMM process is oriented towards assessing individual plant performance, they were unable to separate the issues associated with Comed system-wide performance. This conclusion was the basis for the 10 CFR 50.54(f) letter i        sent to Comed in January 1997. NRC senior managers again considered these corporate-level issues, in particular the cyclical performance that has marked the performance of many of the Comed facilities.
LaSalle, Dresden, and Quad Cities.
l l         The senior managers focused on the limited measurable progress from Comed's improvement
- The senior managers recalled discussions from the January 1997, June 1997, and January 1998 SMMs during which they recognized that while the SMM process is oriented towards assessing individual plant performance, they were unable to separate the issues associated with Comed system-wide performance. This conclusion was the basis for the 10 CFR 50.54(f) letter sent to Comed in January 1997. NRC senior managers again considered these corporate-level i
!        initiatives. Since the last SMM 1) LaSalle remained shut down,2) while Dresden safely demonstrated dual-unit operations, it experienced several reactor scrams, and 3) Quad Cities just recently restarted following an extended outage. While it is too early for outcome performance indicators to show that operational performance is improving as a result of the Strategic Reform Initiatives, the senior managers expressed greater confidence in both the f'
issues, in particular the cyclical performance that has marked the performance of many of the Comed facilities.
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The senior managers focused on the limited measurable progress from Comed's improvement initiatives. Since the last SMM 1) LaSalle remained shut down,2) while Dresden safely demonstrated dual-unit operations, it experienced several reactor scrams, and 3) Quad Cities just recently restarted following an extended outage. While it is too early for outcome performance indicators to show that operational performance is improving as a result of the Strategic Reform Initiatives, the senior managers expressed greater confidence in both the f'
NRC's and licensee's processes for monitoring and engaging indications of cyclical performance at Comed's nuclear facilities.
NRC's and licensee's processes for monitoring and engaging indications of cyclical performance at Comed's nuclear facilities.
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SPECIFIC DISCUSSION OF PROBLEM FACILITIES i
SPECIFIC DISCUSSION OF PROBLEM FACILITIES i
Cateaorv 1: Plants That Have Been Removed From The List Of Problem Facilities CRYSTAL RIVER Backaround Information:
Cateaorv 1: Plants That Have Been Removed From The List Of Problem Facilities CRYSTAL RIVER Backaround Information:
l Declining performance at Crystal River 3 (CR3) was first discussed during the June 1996 Senior Management Meeting (SMM). Concerns at CR3 involved Florida Power Corporation's (FPC) u          handling of several design issues, their non-conservative interpretation of certain NRC regulations, and weaknesses in operator performance, corrective actions, and management
l Declining performance at Crystal River 3 (CR3) was first discussed during the June 1996 Senior Management Meeting (SMM). Concerns at CR3 involved Florida Power Corporation's (FPC) handling of several design issues, their non-conservative interpretation of certain NRC u
        . oversight. At the January 1997 SMM, CR3 was placed on the Watch List as a Category 2 plant, due to the continuing decline in overall safety performance. These performance lesues included weaknesses in the licensee's design change processes. A Confirmatory Action Letter (CAL) was issued on March 4,1997, requiring NRC concurrence for the restart of CR3 prior to entering Mode 2. At the June 1997 SMM, the senior NRC management acknowledged that the plant was in an extended shutdown and in the process of determining its extent-of-condition. At that                                               l point it was too early to evaluate the effect of the performance improvement plans ar.d l
regulations, and weaknesses in operator performance, corrective actions, and management
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. oversight. At the January 1997 SMM, CR3 was placed on the Watch List as a Category 2 plant, due to the continuing decline in overall safety performance. These performance lesues included weaknesses in the licensee's design change processes. A Confirmatory Action Letter (CAL) was issued on March 4,1997, requiring NRC concurrence for the restart of CR3 prior to entering Mode 2. At the June 1997 SMM, the senior NRC management acknowledged that the plant was in an extended shutdown and in the process of determining its extent-of-condition. At that l
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point it was too early to evaluate the effect of the performance improvement plans ar.d l
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considerations for maintaining increased agency attention outweighed those for decreasing agency attention. Therefore, CR3 continued to be designated as a Category 2 plant.
considerations for maintaining increased agency attention outweighed those for decreasing agency attention. Therefore, CR3 continued to be designated as a Category 2 plant.
During the January 1998 SMM, NRC management noted overall performance at CR3 had improved and FPC had made substantive progress toward their planned restart. The programmatic areas of design control,10 CFR 50.59 evaluations, and corrective actions had been inspected and found adequate. NRC senior managers noted in reviewing the removal matrix that given the plant's shutdown condition it had yet to achieve a period of sustained operational performance. Concems were also raised regarding the reconstitution of the plant design basis due to its vintage and design. For these reasons CR3 continued to be designated as a Category 2 plant.
During the January 1998 SMM, NRC management noted overall performance at CR3 had improved and FPC had made substantive progress toward their planned restart. The programmatic areas of design control,10 CFR 50.59 evaluations, and corrective actions had been inspected and found adequate. NRC senior managers noted in reviewing the removal matrix that given the plant's shutdown condition it had yet to achieve a period of sustained operational performance. Concems were also raised regarding the reconstitution of the plant design basis due to its vintage and design. For these reasons CR3 continued to be designated as a Category 2 plant.
l t        The NRC Restart Panel developed five major areas of concern to capture broad performance         ,
l The NRC Restart Panel developed five major areas of concern to capture broad performance t
problems which included: management oversight, engineering effectiveness, knowledge of design basis; compliance with regulations, and operator performance. These areas were thoroughly addressed by licensee management and performance in these areas as well as l       overall performance has continued to improve. Inspections in these areas prior to restart noted l       improved performance in all five areas.- CR3 was released from the CAL on January 30,1998, i       and achieved full power on February 10,1998.
problems which included: management oversight, engineering effectiveness, knowledge of design basis; compliance with regulations, and operator performance. These areas were thoroughly addressed by licensee management and performance in these areas as well as l
CR3 senior management turned over during the outage and subsequently replaced a number of upper and middle managers with personnel from outside the company. The new management
overall performance has continued to improve. Inspections in these areas prior to restart noted l
: l.       has taken the initiative to correct longstanding problems and improve programs. Performance l       has also improved in the area of licensing.
improved performance in all five areas.- CR3 was released from the CAL on January 30,1998, i
and achieved full power on February 10,1998.
CR3 senior management turned over during the outage and subsequently replaced a number of upper and middle managers with personnel from outside the company. The new management l.
has taken the initiative to correct longstanding problems and improve programs. Performance l
has also improved in the area of licensing.
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Operational performance since plant startup has been good and operators have taken more of a leadership role than in the past. Licensee management provided strong oversight of operations following plant startup and has stressed conservative operations over competing schedule pressures.'' Material condition continued to improve with a small backlog of corrective maintenance items. Timely correction of operator workarounds and reduction of control board l       deficiencies continues to receive emphasis. Management established a low threshold for
Operational performance since plant startup has been good and operators have taken more of a leadership role than in the past. Licensee management provided strong oversight of operations following plant startup and has stressed conservative operations over competing schedule pressures.'' Material condition continued to improve with a small backlog of corrective maintenance items. Timely correction of operator workarounds and reduction of control board l
!        identifying problems and self-assessments have been effective in identifying areas for-l     ' improvement.'
deficiencies continues to receive emphasis. Management established a low threshold for identifying problems and self-assessments have been effective in identifying areas for-l
: l.       Areas'where the licensee is pursuing additional improvement include processes for plant i       modifications, procedure changes and clearance tagging. These areas are being addressed by i       licensee management, as are the reduction of the engineering backlog and performance problems attributable to poor communications among operations, engineering and maintenance organizations.
' improvement.'
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Areas'where the licensee is pursuing additional improvement include processes for plant i
modifications, procedure changes and clearance tagging. These areas are being addressed by i
licensee management, as are the reduction of the engineering backlog and performance problems attributable to poor communications among operations, engineering and maintenance organizations.
SMM Discussion:
SMM Discussion:
The senior managers considered the Watch List removal matrix in determining the appropriate agency response to the identified performance concems. In reviewing the Watch List removal matrix, the senior managers noted that Crystal River 3 met all the criteria for removal from the watch list and had demonstrated sustained performance improvement. The senior managers noted that Florida Power Corporation had substantially improved plant material condition,       3 i
The senior managers considered the Watch List removal matrix in determining the appropriate agency response to the identified performance concems. In reviewing the Watch List removal matrix, the senior managers noted that Crystal River 3 met all the criteria for removal from the watch list and had demonstrated sustained performance improvement. The senior managers noted that Florida Power Corporation had substantially improved plant material condition, 3
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management oversight and effectiveness, engineering, and operator training. NRC performance indicators confirmed continued improving trends.
management oversight and effectiveness, engineering, and operator training. NRC performance indicators confirmed continued improving trends.
The senior managers concluded that Crystal River 3 had taken effective action to correct their
The senior managers concluded that Crystal River 3 had taken effective action to correct their
!          - identified problems and to implement programs for improved performance. As a result, no j           further agency-level attention is necessary beyond that provided by the regional office to ensure i
- identified problems and to implement programs for improved performance. As a result, no j
improvement continues. Crystal River 3 was classified as a Category 1 facility.
further agency-level attention is necessary beyond that provided by the regional office to ensure improvement continues. Crystal River 3 was classified as a Category 1 facility.
l SALEM Backaround Discussion:
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SALEM Backaround Discussion:
Salem Units 1 and 2 were first discussed at the January 1990 Senior Management Meeting
Salem Units 1 and 2 were first discussed at the January 1990 Senior Management Meeting
          - (SMM) and have been subsequently discussed at every SMM since June 1994. Both units were shutdown in May and June,1995, respectively to correct longstanding equipment deficiencies, l           poor material condition, weak management oversight, and ineffective corrective actions. As a result of the January 1997 SMM, the Salem units were designated as a Category 2 watch list l           facility. On August 6,1997, the NRC concluded that the licensee improved performance L           sufficiently to warrant modification of the 1995 Confirmatory Action Letter (CAL) to allow restart l           of Unit 2. Senior licensee management provided effective oversight of the Unit 2 restart effort and successfully fostered a conservative and deliberate operating ethic among the operations l           staff. Since the most recent SMM, the plant operated well with the exception of an emergency l           diesel generator (EDG) turbocharger failure which resulted in a forced outage on Unit 2 of about -
- (SMM) and have been subsequently discussed at every SMM since June 1994. Both units were shutdown in May and June,1995, respectively to correct longstanding equipment deficiencies, l
poor material condition, weak management oversight, and ineffective corrective actions. As a result of the January 1997 SMM, the Salem units were designated as a Category 2 watch list l
facility. On August 6,1997, the NRC concluded that the licensee improved performance L
sufficiently to warrant modification of the 1995 Confirmatory Action Letter (CAL) to allow restart l
of Unit 2. Senior licensee management provided effective oversight of the Unit 2 restart effort and successfully fostered a conservative and deliberate operating ethic among the operations l
staff. Since the most recent SMM, the plant operated well with the exception of an emergency l
diesel generator (EDG) turbocharger failure which resulted in a forced outage on Unit 2 of about -
a month. Also since the most recent SMM, performance improved sufficiently on Unit 1 to warrant modification of the CAL to allow restart of that unit. The Unit 1 heatup and restart activities were conducted in a conservative manner. Operator performance during the controlled shutdown of Unit 2 for the forced outage and during the startup of Unit 1 was excellent.
a month. Also since the most recent SMM, performance improved sufficiently on Unit 1 to warrant modification of the CAL to allow restart of that unit. The Unit 1 heatup and restart activities were conducted in a conservative manner. Operator performance during the controlled shutdown of Unit 2 for the forced outage and during the startup of Unit 1 was excellent.
!          The licensee has assembled a strong management team who set high standards and exhibited a good safety ethic. Management and independent oversight of the station were effective in i
The licensee has assembled a strong management team who set high standards and exhibited a good safety ethic. Management and independent oversight of the station were effective in i
enhancing station performance. Strong management attention resulted in significant improvements in the areas of operator workarounds, control room deficiencies, and the
enhancing station performance. Strong management attention resulted in significant improvements in the areas of operator workarounds, control room deficiencies, and the operations procedure revision backlog. Management was also effective in establishing a low threshold of reporting problems throughout the plant. Overall, management fostered thorough, independent, and self-critical oversight of station activities, as well as effective self-assessments in the major plant departments.
;            operations procedure revision backlog. Management was also effective in establishing a low
The maintenance organization exhibited strong management and teamwork, but continued to be l
!-          threshold of reporting problems throughout the plant. Overall, management fostered thorough, independent, and self-critical oversight of station activities, as well as effective self-assessments in the major plant departments.
challenged by some weaknesses in the planning and scheduling process, emergent work L
The maintenance organization exhibited strong management and teamwork, but continued to be l           challenged by some weaknesses in the planning and scheduling process, emergent work L           activities, and the workload associated with efforts to reduce the maintenance backlog. The I           corrective maintenance backlog was large; however, it was properly managed and a reasonable I
activities, and the workload associated with efforts to reduce the maintenance backlog. The I
plan was developed to reduce it. The preventative maintenance backlog was also large;                         I however, safety-related preventative maintenance was performed as required and management actions were effective in reducing the backlog. The maintenance self-assessment and corrective action program continued to effectively identify and evaluate problems. For example, the                     j licensee's self-assessment of their maintenance rule program was thorough and addressed                       j
corrective maintenance backlog was large; however, it was properly managed and a reasonable I
plan was developed to reduce it. The preventative maintenance backlog was also large; I
however, safety-related preventative maintenance was performed as required and management actions were effective in reducing the backlog. The maintenance self-assessment and corrective action program continued to effectively identify and evaluate problems. For example, the j
licensee's self-assessment of their maintenance rule program was thorough and addressed j


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l                                                                7 L
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                . many weaknesses of the station-wide program. Overall, rnaterial condition of both units               l improved significantly and was considered to be good, l               The engineering organization continued to provide leadership in important plant activities.
. many weaknesses of the station-wide program. Overall, rnaterial condition of both units improved significantly and was considered to be good, l
l               System Engineering was effective in their support of plant operations and was actively involved in the resolution of emergent plant events. For example, the root cause investigation associated with the EDG turbocharger failure was excellent. Improvements were aLo noted in the in the performance of Design Engineering. Although the backlog of engineering activities remains large, the licensee has properly prioritized it. Numerous equipment modifications were l               effectively implemented to improve plant performance. Finally, the licensee was effective in l               improving a broad spectrum of engineering programs. For example, notable improvements were made to the fuse control program and the vendor manual program.
The engineering organization continued to provide leadership in important plant activities.
SMM Discussion-                                                                                       ,
l System Engineering was effective in their support of plant operations and was actively involved in the resolution of emergent plant events. For example, the root cause investigation associated with the EDG turbocharger failure was excellent. Improvements were aLo noted in the in the performance of Design Engineering. Although the backlog of engineering activities remains large, the licensee has properly prioritized it. Numerous equipment modifications were l
i The senior managers considered the Watch List removal matrix in determining the appropriate agency response to the identified performance concerns. The senior managers noted that               )
effectively implemented to improve plant performance. Finally, the licensee was effective in l
l               Salem met all the criteria (or removal from the Watch List, including the demonstration of           j l               sustained, successful plant performance. The senior managers noted the successful startup             !
improving a broad spectrum of engineering programs. For example, notable improvements were made to the fuse control program and the vendor manual program.
l                and operation of Unit 1 and continued good operational performance of Unit 2. Also,-the senior       1 l               managers noted that the licensee substantially improved plant material condition, safety culture, and management oversight and effectiveness. The Salem management team set high standards for performance at the site, provided the resources necessary to improve operational       !
SMM Discussion-i The senior managers considered the Watch List removal matrix in determining the appropriate agency response to the identified performance concerns. The senior managers noted that
performance, and instituted a robust self-assessment process.                                         l
)
!                While the maintenance backlog remained high, licensee management demonstrated a strong               )
l Salem met all the criteria (or removal from the Watch List, including the demonstration of j
understanding of the Wvidual and cumulative effects of the backlog and is effectively managing       l the prioritization are klution sf backlog items. The senior managers also discussed                   !
l sustained, successful plant performance. The senior managers noted the successful startup l
engineering performance at Salem and concluded that, while it is contending with large backlogs         :
and operation of Unit 1 and continued good operational performance of Unit 2. Also,-the senior 1
that resulted from discovery efforts during the outage, the engineering organization is providing -
l managers noted that the licensee substantially improved plant material condition, safety culture, and management oversight and effectiveness. The Salem management team set high standards for performance at the site, provided the resources necessary to improve operational performance, and instituted a robust self-assessment process.
While the maintenance backlog remained high, licensee management demonstrated a strong
)
understanding of the Wvidual and cumulative effects of the backlog and is effectively managing the prioritization are klution sf backlog items. The senior managers also discussed engineering performance at Salem and concluded that, while it is contending with large backlogs that resulted from discovery efforts during the outage, the engineering organization is providing -
good support to the station.
good support to the station.
The senior managers concluded that Salem had taken effective action to correct their identified problems and to implement programs for improved performance. As a result, no further agency l               level attention is necessary beyond that provided by the regional office to ensure improvement
The senior managers concluded that Salem had taken effective action to correct their identified problems and to implement programs for improved performance. As a result, no further agency l
!                continues. The senior managers determined that the Watch List removal matrix and SMM                 ,
level attention is necessary beyond that provided by the regional office to ensure improvement continues. The senior managers determined that the Watch List removal matrix and SMM L
L                presentation supported this decision. Salem was designated as a Category 1 facility.
presentation supported this decision. Salem was designated as a Category 1 facility.
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t-i DRESDEN r
i DRESDEN r                 Backaround Information:
Backaround Information:
l Dresden was first placed on the NRC Watch List in June 1987, removed in December 1988, and again placed on the Watch List in January 1992. Significant contributors to the decision to place Dresden on the Watch List a second time included weaknesses in: procedure quality and adherence, communications, execution of management expectations, plant material condition,
l Dresden was first placed on the NRC Watch List in June 1987, removed in December 1988, and again placed on the Watch List in January 1992. Significant contributors to the decision to place Dresden on the Watch List a second time included weaknesses in: procedure quality and adherence, communications, execution of management expectations, plant material condition,


e 8
e 8
supervision and control of work activities, work performance, and engineering and licensing support. During the June 1996 SMM, senior managers concluded that an independent special team should be formed to evaluate the performance of Dresden station. This evaluation was conducted in the Fall 1996 and the results were presented to the senior managers at the January 1997 SMM. This team concluded that safety performance had significantly improved in plant operations while the level of improvement in engineering had not yet resulted in fully effective problem identification and resolution. The team also concluded that the results of improvement initiatives in radiological protection, maintenance, and self-assessment were mixed and identified significant weaknesses in engineering, design control, and surveillance testing.
supervision and control of work activities, work performance, and engineering and licensing support. During the June 1996 SMM, senior managers concluded that an independent special team should be formed to evaluate the performance of Dresden station. This evaluation was conducted in the Fall 1996 and the results were presented to the senior managers at the January 1997 SMM. This team concluded that safety performance had significantly improved in plant operations while the level of improvement in engineering had not yet resulted in fully effective problem identification and resolution. The team also concluded that the results of improvement initiatives in radiological protection, maintenance, and self-assessment were mixed and identified significant weaknesses in engineering, design control, and surveillance testing.
During the June 1997 SMM, improvement in the Unit 3 operational performance and material condition was noted, but senior agency managers remained concerned about continued operational challenges on Unit 2 created by equipment deficiencies, the engineering difficulties that remained to be addressed, lingering questions about work control, continued weaknesses in     l procedural adherence and continued maintenance issues. NRC senior managers recognized             !
During the June 1997 SMM, improvement in the Unit 3 operational performance and material condition was noted, but senior agency managers remained concerned about continued operational challenges on Unit 2 created by equipment deficiencies, the engineering difficulties that remained to be addressed, lingering questions about work control, continued weaknesses in procedural adherence and continued maintenance issues. NRC senior managers recognized sustained improved performance at Dresden during the January 1998 SMM; however, concerns
sustained improved performance at Dresden during the January 1998 SMM; however, concerns         )
)
:                                                          regarding 1) the continued evidence of cyclic performance by Comed plants and 2) the             ,
regarding 1) the continued evidence of cyclic performance by Comed plants and 2) the adequacy of corporate oversight and involvement in plant operations and problem resolution i
adequacy of corporate oversight and involvement in plant operations and problem resolution       i resulted in Dresden's continued designation as a Category 2 facility.
resulted in Dresden's continued designation as a Category 2 facility.
Recent performance in operations has been good. Operational evolutions are usually conducted in a controlled manner with excellent communications. Operators continued to be l                                                           challenged by scrams and transients caused by material condition deficiencies. There were 6 l                                                           reactor scrams (5 automatic and 1 manual) over a 6 month period, three attributed to engineering performance and three to maintenance activities. Operators responded appropriately to reactor scrams and performed well during associated startuos. The Unit 2 refueling outage in March and April was completed in a Dresden record time of 41 days.
Recent performance in operations has been good. Operational evolutions are usually conducted in a controlled manner with excellent communications. Operators continued to be l
Plant material condition, though greatly improved in recent years due to management focus, still continues to impact plant operations. Improvements were noted in the work control process, but maintenance errors, mainly attributed to inadequate procedures and work instructions, continued to cause equipment problems. Despite these material condition issues, plant equipment             .
challenged by scrams and transients caused by material condition deficiencies. There were 6 l
responded as designed during scrams, minimizing the challenge to operators.
reactor scrams (5 automatic and 1 manual) over a 6 month period, three attributed to engineering performance and three to maintenance activities. Operators responded appropriately to reactor scrams and performed well during associated startuos. The Unit 2 refueling outage in March and April was completed in a Dresden record time of 41 days.
Plant material condition, though greatly improved in recent years due to management focus, still continues to impact plant operations. Improvements were noted in the work control process, but maintenance errors, mainly attributed to inadequate procedures and work instructions, continued to cause equipment problems. Despite these material condition issues, plant equipment responded as designed during scrams, minimizing the challenge to operators.
Based on the effectiveness of engineering staff in identifying and resolving technical issues the NRC closed CAL No, Rill-96-016. Some weaknesses are still present in engineering. Although engineering's support of operations has been adequate, resolution of severallongstanding problems has been ineffective.
Based on the effectiveness of engineering staff in identifying and resolving technical issues the NRC closed CAL No, Rill-96-016. Some weaknesses are still present in engineering. Although engineering's support of operations has been adequate, resolution of severallongstanding problems has been ineffective.
4 Performance in Plant Support has been good. Licensee self assessment has been aggressive and is a developing strength for the last several assessment periods. Self-assessment has continued to identify weaknesses with routine procedural adherence and maintenance activities.
4 Performance in Plant Support has been good. Licensee self assessment has been aggressive and is a developing strength for the last several assessment periods. Self-assessment has continued to identify weaknesses with routine procedural adherence and maintenance activities.
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9 concluded that sustained plant performance was not demonstrated. However, plant performance has improved substantially based on improved conduct of operations and plant material condition. Operators have performed well during the scrams and subsequent startups.
9 concluded that sustained plant performance was not demonstrated. However, plant performance has improved substantially based on improved conduct of operations and plant material condition. Operators have performed well during the scrams and subsequent startups.
The senior managers focused on the six scrams that occurred since December 1997 and
The senior managers focused on the six scrams that occurred since December 1997 and
          ' debated potential insights that could be drawn conceming the overall performance of the site.
' debated potential insights that could be drawn conceming the overall performance of the site.
The senior managers noted that safe dual-unit operations had been achieved since the last SMH and that the scrams were generally the result of historical problems. It was noted that gerate performance during the scrams was good. While the number of scrams was high, plant equimnt responded as designed during the scrams, minimizing the challenge to operators. In       l l
The senior managers noted that safe dual-unit operations had been achieved since the last SMH and that the scrams were generally the result of historical problems. It was noted that gerate performance during the scrams was good. While the number of scrams was high, plant equimnt responded as designed during the scrams, minimizing the challenge to operators. In l
L addgion, due to the general lack of equipment problems during these transients, NRC senior -     I managers gained greater confidence in the reliability of mitigating equipment. The senior         I managers concluded that, contrary to the initial view of the Region, Dresden had sufficiently demonstrated sustained plant performance to meet the removal matrix criteria.
addgion, due to the general lack of equipment problems during these transients, NRC senior -
L managers gained greater confidence in the reliability of mitigating equipment. The senior I
managers concluded that, contrary to the initial view of the Region, Dresden had sufficiently demonstrated sustained plant performance to meet the removal matrix criteria.
The senior managers discussed risk insights associated with Dresden as reflected b the IPE and IPEEE. These discussions focused on equipment reliability experienced during scrams, HPCI system reliability, and recent improvements made to the feedwater level control system The senior managers determined that the level of risk resulting from the reactor trips experienced by Dresden during the period was minimal.
The senior managers discussed risk insights associated with Dresden as reflected b the IPE and IPEEE. These discussions focused on equipment reliability experienced during scrams, HPCI system reliability, and recent improvements made to the feedwater level control system The senior managers determined that the level of risk resulting from the reactor trips experienced by Dresden during the period was minimal.
The senior managers deliberated on Dresden's improved performance in conjunction with the agency's concems over Comed system-wide performance and the performance trends at the other individual Comed nuclear facilities, specifically Quad Cities. While system-wide performance remained an area of NRC focus, the senior managers concluded that Comed's corporate support and oversight of Dresden was adequate to support continued sustained performance. ; In addition, the senior managers concluded that the site had individually achieved a level of performance to support removal from the Watch List during the last twelve months.
The senior managers deliberated on Dresden's improved performance in conjunction with the agency's concems over Comed system-wide performance and the performance trends at the other individual Comed nuclear facilities, specifically Quad Cities. While system-wide performance remained an area of NRC focus, the senior managers concluded that Comed's corporate support and oversight of Dresden was adequate to support continued sustained performance. ; In addition, the senior managers concluded that the site had individually achieved a level of performance to support removal from the Watch List during the last twelve months.
Lastly, the senior managers expressed greater confidence in Comed's ability to monitor and
Lastly, the senior managers expressed greater confidence in Comed's ability to monitor and
          . address cyclical performance.
. address cyclical performance.
The senior managers concluded that Dresden had taken effective action to correct their identified problems and to implement programs for improved performance. As a result, no further NRC special attention is necessary beyond the regional office's current level of monitoring to ensure improvement continues, which includes the continued assessment of Comed corporate support for its nuclear facilities through the NRC's Comed Performance Oversight Panel process. Dresden was classified as a Category 1 facility.
The senior managers concluded that Dresden had taken effective action to correct their identified problems and to implement programs for improved performance. As a result, no further NRC special attention is necessary beyond the regional office's current level of monitoring to ensure improvement continues, which includes the continued assessment of Comed corporate support for its nuclear facilities through the NRC's Comed Performance Oversight Panel process. Dresden was classified as a Category 1 facility.
Catenorv 2: Plants Authorized To Ooerate That The NRC Will Monitor Closelv l
Catenorv 2: Plants Authorized To Ooerate That The NRC Will Monitor Closelv l
MILLSTONE 3 Backaround Information:
MILLSTONE 3 Backaround Information:
Beginning in 1991, the Millstone units have been discussed at every senior management f-         meeting. This is the fourteenth senior management meeting (SMM) that the Millstone Station l
Beginning in 1991, the Millstone units have been discussed at every senior management f-meeting. This is the fourteenth senior management meeting (SMM) that the Millstone Station l
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l


l 10 has been discussed. All three Millstone units, each of which ceased operating at some point during 1995-96, were placed on the Watch List as Category 2 facilities as a result of the January                                                                         l l
10 has been discussed. All three Millstone units, each of which ceased operating at some point during 1995-96, were placed on the Watch List as Category 2 facilities as a result of the January l
1996 SMM. Subsequent to the June 1996 SMM, the Commission identified Millstone as a                                                                                       !
1996 SMM. Subsequent to the June 1996 SMM, the Commission identified Millstone as a Category 3 Watch List plant, which required that the units individually receive Commission l
Category 3 Watch List plant, which required that the units individually receive Commission                                                                               l approval to restart.
approval to restart.
On August 14,1996, the NRC issued a Confirmatory Order directing NNECO to establish an Independent Corrective Actions Verification Program (ICAVP) to verify the adequacy of NNECO's efforts to establish adequate design basis and design controls. The licensee selected Sargent and Lundy as the contractor for Units 1 and 3, and Parsons Power Group as the contractor for Unit 2. The staff approved these selections.
On August 14,1996, the NRC issued a Confirmatory Order directing NNECO to establish an Independent Corrective Actions Verification Program (ICAVP) to verify the adequacy of NNECO's efforts to establish adequate design basis and design controls. The licensee selected Sargent and Lundy as the contractor for Units 1 and 3, and Parsons Power Group as the contractor for Unit 2. The staff approved these selections.
On October 24,1996, the NRC issued an order directing that before the restart of any unit, NNECO must develop and submit to the NRC a comprehensive plan for reviewing and dispositioning safety issues raised by its employees, and ensuring that employees who raise safety concems can do so without fear of retaliation. Additionally the order required the l                                           licensee to hire an independent contractor to monitor the effectiveness of the new program.
On October 24,1996, the NRC issued an order directing that before the restart of any unit, NNECO must develop and submit to the NRC a comprehensive plan for reviewing and dispositioning safety issues raised by its employees, and ensuring that employees who raise safety concems can do so without fear of retaliation. Additionally the order required the l
i                                           NNECO selected L!ttle Harbor Consultants, Inc. for this independent review of the employee concerns program.
licensee to hire an independent contractor to monitor the effectiveness of the new program.
i NNECO selected L!ttle Harbor Consultants, Inc. for this independent review of the employee concerns program.
The agency accumulated enforcement issues for the Millstone site since late 1995, combining regional issues with those from the special inspection conducted in 1996. Over 80 items were identified, ranging from engineering design issues to Office of Investigation findings from wrongdoing cases. A civil penalty of $2.1 million was issued for these findings on December 10, 1997. More recently, on March 9,1998, a civil penalty of $55,000 was issued in association with l
The agency accumulated enforcement issues for the Millstone site since late 1995, combining regional issues with those from the special inspection conducted in 1996. Over 80 items were identified, ranging from engineering design issues to Office of Investigation findings from wrongdoing cases. A civil penalty of $2.1 million was issued for these findings on December 10, 1997. More recently, on March 9,1998, a civil penalty of $55,000 was issued in association with l
the licensee's failure to take adequate corrective ..:tions with respect to the potential for air in
the licensee's failure to take adequate corrective..:tions with respect to the potential for air in certain portions of the recirculation spray system to be swept into the suction of the charging and safety injection pumps during the recirculation phase of a loss-of-coolant accident.
;                                          certain portions of the recirculation spray system to be swept into the suction of the charging and safety injection pumps during the recirculation phase of a loss-of-coolant accident.
l Unit 2 recovery efforts have been delayed significantly due to NNECO management's decision to focus resources on Unit 3 recovery and restart activities. Unit i recovery efforts have been placed on hold pending completion of activities for the other two units. Thus, there has been no significant change in the status of Units 1 and 2 since the last SMM. [On July 21,1998, Northeast Nuclear Energy Company submitted a letter stating their decision to cease operations at Millstone Unit 1.]
l                                           Unit 2 recovery efforts have been delayed significantly due to NNECO management's decision                                                                               ,
to focus resources on Unit 3 recovery and restart activities. Unit i recovery efforts have been                                                                         _
placed on hold pending completion of activities for the other two units. Thus, there has been no                                                                         '
significant change in the status of Units 1 and 2 since the last SMM. [On July 21,1998, Northeast Nuclear Energy Company submitted a letter stating their decision to cease operations at Millstone Unit 1.]
In SECYs 98-090 and 98-119, and in Commission meetings conducted May 1 and June 2,1998, the staff provided the Commission with its assessment of issues related to the Restart Assessment Plan (RAP) for Millstone Unit 3. In SECY 98-119, the staff concluded that the licensee had taken appropriate corrective actions to support the restart of Unit 3. This was based, in part, on the following assessments:
In SECYs 98-090 and 98-119, and in Commission meetings conducted May 1 and June 2,1998, the staff provided the Commission with its assessment of issues related to the Restart Assessment Plan (RAP) for Millstone Unit 3. In SECY 98-119, the staff concluded that the licensee had taken appropriate corrective actions to support the restart of Unit 3. This was based, in part, on the following assessments:
: 1.       NNECO had met the restart requirements of the October 24,1996 Order. The licensee's Employee Concems Program and Safety Conscious Work Environment were well-established and functioning effectively.
1.
NNECO had met the restart requirements of the October 24,1996 Order. The licensee's Employee Concems Program and Safety Conscious Work Environment were well-established and functioning effectively.
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[_                                             _                      - -- - _ _    _ - _ _ - _ _ _ _ _ - _ - - _ - _                        _ _ _ - - - - _ - - - _ - _ _ _ _ - _ _ - - - - _ _ _                A
[_
A


d 11
d 11 2.
: 2.         ' Significant improvements have been made in oversight activities at Millstone. NNECO established an effective self-assessment process and oversight was adequate to support restart of Unit 3.
' Significant improvements have been made in oversight activities at Millstone. NNECO established an effective self-assessment process and oversight was adequate to support restart of Unit 3.
: 3. -         NNECO's Configuration Management Program was effective at identifying and satisfactorily resolving existing nonconformances with the design and licensing bases.
: 3. -
NNECO's Configuration Management Program was effective at identifying and satisfactorily resolving existing nonconformances with the design and licensing bases.
NNECO had also established programs, processes, and procedures for effective configuration management in the future. The Unit 3 ICAVP had been satisfactorily performed and the results of the ICAVP and the staff's oversight provided confidence that Unit 3 is in compliance with its design and licensing bases.
NNECO had also established programs, processes, and procedures for effective configuration management in the future. The Unit 3 ICAVP had been satisfactorily performed and the results of the ICAVP and the staff's oversight provided confidence that Unit 3 is in compliance with its design and licensing bases.
: 4.             Improvements were made to the licensee's corrective action program and this program was adequate to support restart of Unit 3. However, the effectiveness of the corrective action program can be more completely assessed by evaluating long-term performance, and thus, the staff will assess the program again in about 1 year.
4.
l             5.           Significant progress had been made in enhancing overall station performance.
Improvements were made to the licensee's corrective action program and this program was adequate to support restart of Unit 3. However, the effectiveness of the corrective action program can be more completely assessed by evaluating long-term performance, and thus, the staff will assess the program again in about 1 year.
!~                         improvements were noted in the conduct of operations, procedure quality and adherence, operator training, command and control, material condition, maintenance and surveillance, and engineering. Overall, Millstone staff and management were suitable and plant equipment, processes, and programs were in place to support restart and continued operation of Unit 3.
l 5.
!            On June 15,1998, the Commission issued a staff requirements memorandum (SRM) providing its restart authorization for Millstone Unit 3. This decision resulted in changing the Watch List status of Unit 3 from Category 3 to Category 2. This restart authorization was subject to the satisfactory completion of all remaining issues requiring NRC verification. The SRM also designated the EDO as the senior manager responsible for verifying the appropriate aspects of         -
Significant progress had been made in enhancing overall station performance.
Inspection Manual Chapter (MC) 0350 were completed and for approving commencement of actions to restart Unit 3. On June 29,1998, the licensee submitted a letter indicating its readiness to enter Mode 2. On the same day, the NRC's Millstone Restart Assessment Panel completed all of its activities associated with the execution of MC 0350 and completed its review of all of the key technical and programmatic issues captured in the Unit 3 RAP. The Panel also recommended that the EDO provide approval for NNECO to restart Unit 3. By {{letter dated|date=June 29, 1998|text=letter dated June 29,1998}}, the EDO authorized NNECO to commence restart actions.
!~
improvements were noted in the conduct of operations, procedure quality and adherence, operator training, command and control, material condition, maintenance and surveillance, and engineering. Overall, Millstone staff and management were suitable and plant equipment, processes, and programs were in place to support restart and continued operation of Unit 3.
On June 15,1998, the Commission issued a staff requirements memorandum (SRM) providing its restart authorization for Millstone Unit 3. This decision resulted in changing the Watch List status of Unit 3 from Category 3 to Category 2. This restart authorization was subject to the satisfactory completion of all remaining issues requiring NRC verification. The SRM also designated the EDO as the senior manager responsible for verifying the appropriate aspects of Inspection Manual Chapter (MC) 0350 were completed and for approving commencement of actions to restart Unit 3. On June 29,1998, the licensee submitted a letter indicating its readiness to enter Mode 2. On the same day, the NRC's Millstone Restart Assessment Panel completed all of its activities associated with the execution of MC 0350 and completed its review of all of the key technical and programmatic issues captured in the Unit 3 RAP. The Panel also recommended that the EDO provide approval for NNECO to restart Unit 3. By {{letter dated|date=June 29, 1998|text=letter dated June 29,1998}}, the EDO authorized NNECO to commence restart actions.
On June 30,1998, Unit 3 entered Mode 2. While equipment problems, primarily on the secondary side of the plant, have delayed some startup activities, overall equipment and personnel performance was very good. The licensee's performance assessments conducted at all milestones through 100% power, as well as the NRC's inspection activities, have found no significant performance issues.
On June 30,1998, Unit 3 entered Mode 2. While equipment problems, primarily on the secondary side of the plant, have delayed some startup activities, overall equipment and personnel performance was very good. The licensee's performance assessments conducted at all milestones through 100% power, as well as the NRC's inspection activities, have found no significant performance issues.
SMM Discussion:
SMM Discussion:
The senior managers discussed the recent Commission decision to recategorize Millstone Unit 3
The senior managers discussed the recent Commission decision to recategorize Millstone Unit 3
      . as a Category 2 plant. The senior managers focused on the sound operator and equipment                             l performance during the Unit 3 startup and power ascension program. The senior managers                         l
. as a Category 2 plant. The senior managers focused on the sound operator and equipment l
performance during the Unit 3 startup and power ascension program. The senior managers l


L.
L.
12 decided that Millstone Unit 3 would remain a Watch List Category 2 facility. The senior managers did not review considerations for decreasing or maintaining the level of agency           1 attention at Millstone Units 1&2 given their current Category 3 standing. [Due to the licensee's subsequent decision on July 21,1998 to cease power operations at Millstone Unit 1, the Commission, in an SRM dated July 22,1998, directed the staff to no longer list Millstone Unit 1 as a Category 3 facility.)
12 decided that Millstone Unit 3 would remain a Watch List Category 2 facility. The senior managers did not review considerations for decreasing or maintaining the level of agency 1
attention at Millstone Units 1&2 given their current Category 3 standing. [Due to the licensee's subsequent decision on July 21,1998 to cease power operations at Millstone Unit 1, the Commission, in an SRM dated July 22,1998, directed the staff to no longer list Millstone Unit 1 as a Category 3 facility.)
The senior managers discussed the transition plan associated with NRC's oversight of Millstone.
The senior managers discussed the transition plan associated with NRC's oversight of Millstone.
Specifically, the Special Projects Office functions would be merged into the line organization.
Specifically, the Special Projects Office functions would be merged into the line organization.
Oversight of inspection activities would be retumed to Region I and oversight of licensing activities, including the activities related to the employee concerns program and safety conscious work environment, would be returned to the NRR Projects organization. Oversight of the ICAVP process would remain with a distinct organization reporting to NRR's Associate l   - Director for Technical Review.
Oversight of inspection activities would be retumed to Region I and oversight of licensing activities, including the activities related to the employee concerns program and safety conscious work environment, would be returned to the NRR Projects organization. Oversight of the ICAVP process would remain with a distinct organization reporting to NRR's Associate l
- Director for Technical Review.
CLINTON Backaround information:
CLINTON Backaround information:
Clinton Power Station was first discussed during the January 1997 Senior Management Meeting due to an overall decline in plant performance during 1996. The decline was clearly
Clinton Power Station was first discussed during the January 1997 Senior Management Meeting due to an overall decline in plant performance during 1996. The decline was clearly
    ' demonstrated in September 1996 events associated with a reactor recirculation pump seal failure which revealed significant deficiencies including problems with procedural adequacy and adherence, the degree of rigor in conducting operations, and engineering support to operations.
' demonstrated in September 1996 events associated with a reactor recirculation pump seal failure which revealed significant deficiencies including problems with procedural adequacy and adherence, the degree of rigor in conducting operations, and engineering support to operations.
l     Based on the results from the January 1997 SMM, Clinton Power Station received a trending letter.
l Based on the results from the January 1997 SMM, Clinton Power Station received a trending letter.
The licensee's poor performance in operations continued during the next six months. A number of procedural adherence violations continued to occur in addition, similar poor performance was noted in radiation protection. While the material condition of the plant improved as a result of a concerted effort by operations, maintenance, and engineering staff, surveillance program weaknesses and inattention to detail during maintenance activities continued to contribute to equipment performance problems. Furthermore, weak engineering support for the station, incomplete and untimely root cause evaluations and corrective actions, and design errors hindered equipment performance.
The licensee's poor performance in operations continued during the next six months. A number of procedural adherence violations continued to occur in addition, similar poor performance was noted in radiation protection. While the material condition of the plant improved as a result of a concerted effort by operations, maintenance, and engineering staff, surveillance program weaknesses and inattention to detail during maintenance activities continued to contribute to equipment performance problems. Furthermore, weak engineering support for the station, incomplete and untimely root cause evaluations and corrective actions, and design errors hindered equipment performance.
During the June 1997 SMM, NRC senior managers were concerned that the licensee had not developed a comprehensive response to the NRC's January 1997 trending letter. While the           ,
During the June 1997 SMM, NRC senior managers were concerned that the licensee had not developed a comprehensive response to the NRC's January 1997 trending letter. While the licensee had implemented a number of short-term corrective actions, it had not developed a long-term approach to address performance deficiencies. It was not clear to the senior managers that the licensee had a full understanding of the depth and scope of the reasons for the performance issues at Clinton. Therefore the senior managers determined that allowing the licensee to perform an Integrated Safety Assessment (ISA), in lieu of a DET, was an appropriate approach to better understand the reasons for its performance decline and develop applicable long-term corrective actions.
licensee had implemented a number of short-term corrective actions, it had not developed a long-term approach to address performance deficiencies. It was not clear to the senior managers that the licensee had a full understanding of the depth and scope of the reasons for the performance issues at Clinton. Therefore the senior managers determined that allowing the licensee to perform an Integrated Safety Assessment (ISA), in lieu of a DET, was an appropriate approach to better understand the reasons for its performance decline and develop applicable long-term corrective actions.                                                                     i l
i l
1
1


(                                                                                   13 The licensee conducted an ISA from August through October 1997 to review its performance.
(
13 The licensee conducted an ISA from August through October 1997 to review its performance.
The NRC reviewed the effectiveness of the ISA with a Special Evaluation Team (SET). The ISA i
The NRC reviewed the effectiveness of the ISA with a Special Evaluation Team (SET). The ISA i
identified significant weaknesses in the areas of operations, engineering, maintenance and plant support. _ The SET confirmed the ISA's findings and determined that the root causes of these problems were:
identified significant weaknesses in the areas of operations, engineering, maintenance and plant support. _ The SET confirmed the ISA's findings and determined that the root causes of these problems were:
4                   management's inability to establish and implement effective performance standards programs, processes and procedures did not consistently provide defense in depth to assure plant activities were conducted in a safe manner
4 management's inability to establish and implement effective performance standards programs, processes and procedures did not consistently provide defense in depth to assure plant activities were conducted in a safe manner
                          .            .. problem identification was inconsistent and evaluation and corrective actions were generally ineffective j                         .
.. problem identification was inconsistent and evaluation and corrective actions were generally ineffective j
management did not ensure that the infrastructure was suitable to support major l                                           changes l
management did not ensure that the infrastructure was suitable to support major l
changes l
During the January 1998 SMM, NRC senior managers were concemed with the lack of progress by the licensee in developing a comprehensive plan to address performance deficiencies.
During the January 1998 SMM, NRC senior managers were concemed with the lack of progress by the licensee in developing a comprehensive plan to address performance deficiencies.
Despite being shutdown for a considerable length of time, there had not been substantive progress made in addressing the major performance issues at Clinton.- NRC senior managers were also concerned with the licensee's continuing problems associated with procedural inadequacies, a cumbersome work process, operator performance, and ineffective self-assessment act.ivities. Following the January 1998 SMM, Clinton Power Station was placed on the NRC Watch List as a Category 2 plant . In January 1998, PECO Energy was selected by l                         lilinois Power to provide management services for Clinton for the next 3 years. Since that time, most key managers at Clinton have been replaced.
Despite being shutdown for a considerable length of time, there had not been substantive progress made in addressing the major performance issues at Clinton.- NRC senior managers were also concerned with the licensee's continuing problems associated with procedural inadequacies, a cumbersome work process, operator performance, and ineffective self-assessment act.ivities. Following the January 1998 SMM, Clinton Power Station was placed on the NRC Watch List as a Category 2 plant. In January 1998, PECO Energy was selected by l
Based upon the findings of the SET, ISA, other NRC inspection activities, and licensee self-assessment activities, the new management team engaged the facility staff in developing a Plan For Excellence. Some progress towards performance improvement has been observed in the early implementation stages of the Plan For Excellence. The operations department was L                         reorganized and operator performance has generally improved over the past six months. A System Design and Functional Validation of 5 systems was performed to address design control questions. A new corrective action program was implemented and problem identification has improved with the new program. The corrective actions for electrical breaker issues are nearly complete which has allowed the licensee to complete work to make electrical divisions I and 11 operable for the first time since August 1997. In addition, a major plant modification is well
lilinois Power to provide management services for Clinton for the next 3 years. Since that time, most key managers at Clinton have been replaced.
:                        underway to address the degraded voltage concern at Clinton.
Based upon the findings of the SET, ISA, other NRC inspection activities, and licensee self-assessment activities, the new management team engaged the facility staff in developing a Plan For Excellence. Some progress towards performance improvement has been observed in the early implementation stages of the Plan For Excellence. The operations department was L
While some performance improvement has been noted, it has been inconsistent in some areas and is not yet self-sustaining. While there were improvements in conservative decision-making, there were isolated instances where operators engaged in activities that distracted them from monitoring the plant or where operators did not appropriately respond to abnormal plant u                        indications. The licensee is struggling with managing the large backlog of condition reports and many problems remain unresolved. The preventive and corrective maintenance item backlog has grown during the extended outage and remains large. Progress in correcting material condition issues has been slowed by newly identified and recurring material condition problems.
reorganized and operator performance has generally improved over the past six months. A System Design and Functional Validation of 5 systems was performed to address design control questions. A new corrective action program was implemented and problem identification has improved with the new program. The corrective actions for electrical breaker issues are nearly complete which has allowed the licensee to complete work to make electrical divisions I and 11 operable for the first time since August 1997. In addition, a major plant modification is well underway to address the degraded voltage concern at Clinton.
While some performance improvement has been noted, it has been inconsistent in some areas and is not yet self-sustaining. While there were improvements in conservative decision-making, there were isolated instances where operators engaged in activities that distracted them from monitoring the plant or where operators did not appropriately respond to abnormal plant indications. The licensee is struggling with managing the large backlog of condition reports and u
many problems remain unresolved. The preventive and corrective maintenance item backlog has grown during the extended outage and remains large. Progress in correcting material condition issues has been slowed by newly identified and recurring material condition problems.
For example, main control panel deficiencies were reduced to approximately 50 items in August
For example, main control panel deficiencies were reduced to approximately 50 items in August
                        '1997, but work prioritization weaknesses led to an increase of over 200 items in the subsequent l
'1997, but work prioritization weaknesses led to an increase of over 200 items in the subsequent


l l                                                                                                                                 14 months. . A new work control process has been implemented, but is not yet effective in ensuring proper prioritization and accomplishment of work.
l l
j                                                                               Performance improvement initiatives addressing these and other areas are contained in the Plan for. Excellence. The plan has been developed through a robust process and implementation has begun; however, to a great extent, the Pl < . remains to be fully implemented and requires continued monitoring.
14 months.. A new work control process has been implemented, but is not yet effective in ensuring proper prioritization and accomplishment of work.
j Performance improvement initiatives addressing these and other areas are contained in the Plan for. Excellence. The plan has been developed through a robust process and implementation has begun; however, to a great extent, the Pl <. remains to be fully implemented and requires continued monitoring.
!=
!=
l SMM Discussion, t
l SMM Discussion, t
The senior managers considered the Watch List removal matrix in determining the appropriate
The senior managers considered the Watch List removal matrix in determining the appropriate i.
: i.                                                                               agency response to the identified performance concems. In reviewing the Watch List removal
agency response to the identified performance concems. In reviewing the Watch List removal matrix, the senior managers focused on the numerous criteria that the plant had not yet '
!                                                                              matrix, the senior managers focused on the numerous criteria that the plant had not yet '
l achieved. The senior managers discussed the licensee's organizational changes and decision l
l                                                                               achieved. The senior managers discussed the licensee's organizational changes and decision l                                                                               to extend the shutdown in order to complete human and hardware improvements, such as those I                                                                               associated with the electrical breaker and degraded voltage concerns. It was noted that while management oversight at the facility nad improved and a new comprehensive recovery plan and corrective action program had been developed, equipment condition and human performance           i
to extend the shutdown in order to complete human and hardware improvements, such as those I
'                                                                              problems continued to surface since the last SMM, indicating that these programs were still in
associated with the electrical breaker and degraded voltage concerns. It was noted that while management oversight at the facility nad improved and a new comprehensive recovery plan and corrective action program had been developed, equipment condition and human performance i
                                                                              ' the early stages of implementation. NRC performance indicators revealed several concerns         -l including long-standing design issues. The senior managers determined that there was a             !
l problems continued to surface since the last SMM, indicating that these programs were still in
continued need for high level NRC attention at this site.                                         l The senior managers decided that Clinton would remain a Watch List Category 2 facility.
' the early stages of implementation. NRC performance indicators revealed several concerns
-l including long-standing design issues. The senior managers determined that there was a continued need for high level NRC attention at this site.
The senior managers decided that Clinton would remain a Watch List Category 2 facility.
LASALLE Backaround Information:
LASALLE Backaround Information:
l                                                                               LaSalle was given a trending letter in January 1994, due to concems about poor radiological
l LaSalle was given a trending letter in January 1994, due to concems about poor radiological work practices, declining material condition, declining personnel performance, and NRC staff ll concems about the licensee's ability to pursue and resolve root causes for these issues. By January 1995, the licensee's initiatives were found to be effective in arresting these adverse trends and the licensee was sent a letter informing them of this observation and urging the continuation of improvement initiatives. Improvement in plant material condition and engineering
!                                                                              work practices, declining material condition, declining personnel performance, and NRC staff ll                                                                               concems about the licensee's ability to pursue and resolve root causes for these issues. By January 1995, the licensee's initiatives were found to be effective in arresting these adverse trends and the licensee was sent a letter informing them of this observation and urging the continuation of improvement initiatives. Improvement in plant material condition and engineering
, effectiveness was limited during 1995 and the first six months of 1996. The significant amount of emergent work and difficulties in planning and executing work hindered progress in L
                                                                                , effectiveness was limited during 1995 and the first six months of 1996. The significant amount of emergent work and difficulties in planning and executing work hindered progress in L                                                                               implementing the station material condition improvement plan during the last six months of 1996.
implementing the station material condition improvement plan during the last six months of 1996.
In June 1996, a risk-significant event occurred involving the injection of large quantities of expandable foam sealant into the safety-related service water tunnel. The NRC issued a
In June 1996, a risk-significant event occurred involving the injection of large quantities of expandable foam sealant into the safety-related service water tunnel. The NRC issued a
                                                                                $650,000 civil penalty to the licensee for violations associated with this event. Following the January 1997 SMM, LaSalle was placed on the NRC watch list as a Category 2 facility.
$650,000 civil penalty to the licensee for violations associated with this event. Following the January 1997 SMM, LaSalle was placed on the NRC watch list as a Category 2 facility.
Both units at LaSalle have been shut down since September 1996 to address a variety of human performance deficiencies and hardware problems. In response to a number of performance issues identified by the NRC and through licensee self-assessments, the licensee developed a i.
Both units at LaSalle have been shut down since September 1996 to address a variety of human performance deficiencies and hardware problems. In response to a number of performance issues identified by the NRC and through licensee self-assessments, the licensee developed a i.


I 15 comprehensive restart action plan.
I 15 comprehensive restart action plan.
During the January 1998 SMM it was noted that overall performance at LaSalle had shown signs of improvement commensurate'with the status of the Restart Plan. The licensee's efforts had resulted in improvement in several areas, although the improvement was not yet consistent and continued focus was considered necessary to sustain the improving trend. The licensee had made improvements to the corrective action process and management at LaSalle had made a substantive effort to identify its material condition problems through system reviews. NRC L                                         senior managers noted that the plant was still immersed in an extensive shutdown, with a substantial amount of work left to be accomplished. Additionally, a large portion of the Watch List removal matrix items had yet to be completed or assessed.
During the January 1998 SMM it was noted that overall performance at LaSalle had shown signs of improvement commensurate'with the status of the Restart Plan. The licensee's efforts had resulted in improvement in several areas, although the improvement was not yet consistent and continued focus was considered necessary to sustain the improving trend. The licensee had made improvements to the corrective action process and management at LaSalle had made a substantive effort to identify its material condition problems through system reviews. NRC L
Since the last SMM the licensee has continued to implement the programmatic changes described in its Restart Plan. Improvement has been noted in the licensee's ability to identify L                                         problems and determine root causes. Licensee self. assessment activities are raising i
senior managers noted that the plant was still immersed in an extensive shutdown, with a substantial amount of work left to be accomplished. Additionally, a large portion of the Watch List removal matrix items had yet to be completed or assessed.
performance expectations. ~ Additional improvement is needed in ensuring appropriate implementation of corrective actions.-                                                                                                                                   l l
Since the last SMM the licensee has continued to implement the programmatic changes described in its Restart Plan. Improvement has been noted in the licensee's ability to identify L
Many material condition improvements and design changes have been completed to correct
problems and determine root causes. Licensee self. assessment activities are raising i
!                                          design deficiencies, operator workarounds, temporary alterations, and degraded equipment. A l                                         number of the modifications have been extensive and are indicative of management's
performance expectations. ~ Additional improvement is needed in ensuring appropriate implementation of corrective actions.-
;                                          commitment to fix long-standing equipment problems; however, the scope of identified material L                                         condition problems that the licensee plans to resolve following restart remains a concern.
Many material condition improvements and design changes have been completed to correct design deficiencies, operator workarounds, temporary alterations, and degraded equipment. A l
Various engineering programs, such as setpoint control, fuse control and inservice testing still l                                         have work remaining. The adequacy of management oversight and assessment of the aggregate effect of the material condition and design conformance issues remains a concern.
number of the modifications have been extensive and are indicative of management's commitment to fix long-standing equipment problems; however, the scope of identified material L
                                        ' Supervisors and operators received training to address human performance errors and personnel performance has improved in all areas. Activity level at the plant continues to                                                                               !
condition problems that the licensee plans to resolve following restart remains a concern.
increase as the licensee approaches the planned startup date of July 28,1998. An NRC restart '                                                                           ;
Various engineering programs, such as setpoint control, fuse control and inservice testing still l
have work remaining. The adequacy of management oversight and assessment of the aggregate effect of the material condition and design conformance issues remains a concern.
' Supervisors and operators received training to address human performance errors and personnel performance has improved in all areas. Activity level at the plant continues to increase as the licensee approaches the planned startup date of July 28,1998. An NRC restart '
readiness inspection has been scheduled prior to startup to evaluate licensee performance during a more challenging period. The NRC Oversight Panel continues to hold public meetings with licensee management.
readiness inspection has been scheduled prior to startup to evaluate licensee performance during a more challenging period. The NRC Oversight Panel continues to hold public meetings with licensee management.
SMM Discussion-                                                                                                                                                         I The senior managers considered the Watch List removal matrix in determining the appropriate agency response to the identified performance concems. Although the licensee is making
SMM Discussion-I The senior managers considered the Watch List removal matrix in determining the appropriate agency response to the identified performance concems. Although the licensee is making
                                          . significant progress toward resolving historical performance problems, particularly in correcting
. significant progress toward resolving historical performance problems, particularly in correcting
(.                                         material deficiencies, improvements are still in the early stages and have not been in place long                                                                       i enough to be either assessed or self-sustaining. Desired improvements in operator                                                                                       '
(.
l                                          performance, including procedure adherence, have not yet been fully demonstrated and the l                                         ongoing procedure upgrade program has not been completed. Consistent and effective root
material deficiencies, improvements are still in the early stages and have not been in place long i
                                        . cause analysis still relies heavily on oversight organizations. Substantial non-outage maintenance backlogs remain and will not be reduced until after restart. Both units have remained shut down since September 1996 and thus sustained, successful plant performance has not yet been demonstrated.. Also, as a result of the extended outage on both units, l
enough to be either assessed or self-sustaining. Desired improvements in operator l
performance, including procedure adherence, have not yet been fully demonstrated and the l
ongoing procedure upgrade program has not been completed. Consistent and effective root
. cause analysis still relies heavily on oversight organizations. Substantial non-outage maintenance backlogs remain and will not be reduced until after restart. Both units have remained shut down since September 1996 and thus sustained, successful plant performance has not yet been demonstrated.. Also, as a result of the extended outage on both units, l
?
?


d l
d 16 performance indicators provide limited insights regarding performance trends.
16 performance indicators provide limited insights regarding performance trends.
The senior managers decided that LaSalle would remain a Watch List Category 2 facility.
;                      The senior managers decided that LaSalle would remain a Watch List Category 2 facility.                                                                         I i
i Category 3: Shutdown Plants Reauirina NRC Authorization To Ooerate And Which The NRC i
;                      Category 3: Shutdown Plants Reauirina NRC Authorization To Ooerate And Which The NRC                                                                           i Will Monitor Closelv                                                               i i
i Will Monitor Closelv i
i                                                                                                                                                 MILLSTONE 1 & 2 l
i MILLSTONE 1 & 2 (Please refer to the Millstone 3 discussion above.)
(Please refer to the Millstone 3 discussion above.)
Note: In July 1998, the senior managers did not review considerations for decreasing or j
Note: In July 1998, the senior managers did not review considerations for decreasing or                                                                         j maintaining the level of agency attention at Millstone Units 1&2, given their Category 3 standing.
maintaining the level of agency attention at Millstone Units 1&2, given their Category 3 standing.
On July 21,1998, Northeast Nuclear Energy Company submitted a letter stating their decision to cease operations at Millstone Unit 1. In an SRM dated July 22,1998, the Commission directed the staff to no longer list Millstone Unit 1 as a Category 3 facility.                                                                                         l Trending:                                                                   Plants Receiving a Trending Letter                                                 l D.C. COOK Backaround Information This is the first time D.C. Cook has been discussed at the SMM. The SALP report issued on March 19,1998 indicated a significant decline in licensee performance in the area of                                                                           !
On July 21,1998, Northeast Nuclear Energy Company submitted a letter stating their decision to cease operations at Millstone Unit 1. In an SRM dated July 22,1998, the Commission directed the staff to no longer list Millstone Unit 1 as a Category 3 facility.
engineering. An NRC Architect Engineering (A/E) team inspection, conducted from August 4                                                                       ;
l Trending:
through September 12,1997, resulted in the identification of significant weakness in design control and several design basis issues. After further review of these issues, the licensee                                                                     l identified that the units operated outside the design basis on multiple occasions and determined                                                               ,
Plants Receiving a Trending Letter D.C. COOK Backaround Information This is the first time D.C. Cook has been discussed at the SMM. The SALP report issued on March 19,1998 indicated a significant decline in licensee performance in the area of engineering. An NRC Architect Engineering (A/E) team inspection, conducted from August 4 through September 12,1997, resulted in the identification of significant weakness in design control and several design basis issues. After further review of these issues, the licensee identified that the units operated outside the design basis on multiple occasions and determined that several safety systems were inoperable including the refueling water storage tank, residual l
that several safety systems were inoperable including the refueling water storage tank, residual                                                               l l                     heat removal system, and portions of the service water, instrument air and component cooling water systems. The installation of fibrous material inside the containment and the potential blockage of ventilation holes in the containment recirculation sump which could have rendered the emergency core cooling system inoperable, two issues that were identified through NRC                                                                       !
l heat removal system, and portions of the service water, instrument air and component cooling water systems. The installation of fibrous material inside the containment and the potential blockage of ventilation holes in the containment recirculation sump which could have rendered the emergency core cooling system inoperable, two issues that were identified through NRC inspection, also exemplified the engineering program deficiencies in design changes and licensing basis reviews. The licensee shutdown both units to address the concerns revealed through the Architect Engineering inspection.
inspection, also exemplified the engineering program deficiencies in design changes and licensing basis reviews. The licensee shutdown both units to address the concerns revealed through the Architect Engineering inspection.
j Performance in the area of operations remained relatively good with improvement noted in I
j                     Performance in the area of operations remained relatively good with improvement noted in I                     control room command and control due to increased management attention. In the area of maintenance, some improvements were noted in procedure quality and adherence, identified as problem areas during the previous P! ant Performance Review assessment. However, as noted above, the material condition of the plant degraded to the point where the operability of some safety systems was questionable. Performance in the area of plant support was good but some problems were noted with radiation worker practices and security force performance. NRC
control room command and control due to increased management attention. In the area of maintenance, some improvements were noted in procedure quality and adherence, identified as problem areas during the previous P! ant Performance Review assessment. However, as noted above, the material condition of the plant degraded to the point where the operability of some safety systems was questionable. Performance in the area of plant support was good but some problems were noted with radiation worker practices and security force performance. NRC


t V.
t V.
l l                                                                                                                     17 inspectors continued to find examples of the licensee's failure to understand and control the design basis of the plant and the failure to provide quality engineering support to the facility.
l l
17 inspectors continued to find examples of the licensee's failure to understand and control the design basis of the plant and the failure to provide quality engineering support to the facility.
Examples included the failure to update the Final Safety Analysis Report regarding the design basis of the containment ice condenser, the failure to follow the established design control process for ice condenser modifications, and the failure to implement prompt corrective actions
Examples included the failure to update the Final Safety Analysis Report regarding the design basis of the containment ice condenser, the failure to follow the established design control process for ice condenser modifications, and the failure to implement prompt corrective actions
                                                              ' for ice condenser conditions adverse to quality.
' for ice condenser conditions adverse to quality.
On March 7,'1998, the licensee implemented a Restart Plan that required system engineering reviews /walkdowns of 21 risk significant systems. Findings from these walkdowns are reviewed
On March 7,'1998, the licensee implemented a Restart Plan that required system engineering reviews /walkdowns of 21 risk significant systems. Findings from these walkdowns are reviewed by the System Engineering Review Board (SERB) to determine which issues constitute restart items. The SERB assessments are reviewed by a Restart Oversight Committee for approval of restart items. The Restart Plan activities are assessed by the Senior Management Review Team (SMRT). The !icensee also instituted functional area, programmatic, and containment assessments. The containment assessment was initiatad in response to the NRC inspection L
!                                                                    by the System Engineering Review Board (SERB) to determine which issues constitute restart items. The SERB assessments are reviewed by a Restart Oversight Committee for approval of restart items. The Restart Plan activities are assessed by the Senior Management Review Team (SMRT). The !icensee also instituted functional area, programmatic, and containment assessments. The containment assessment was initiatad in response to the NRC inspection findings specific to containment related systems. The other assessments are an extension c '
findings specific to containment related systems. The other assessments are an extension c '
L the system reviews and are designed to ensure a broad assessment of plant systems, processes and procedures.
the system reviews and are designed to ensure a broad assessment of plant systems, processes and procedures.
SMM Discussion The senior managers considered the following factors in determining the appropriate agency response to the identified performance concerns:
SMM Discussion The senior managers considered the following factors in determining the appropriate agency response to the identified performance concerns:
  .                                                                                  ARGUMENTS FOR MAINTAINING CURRENT AGENCY ATTENTION l
ARGUMENTS FOR MAINTAINING CURRENT AGENCY ATTENTION Effectiveness of Licensee Self-Assessment l
                                                                    .        Effectiveness of Licensee Self-Assessment
l'
                                                                                                                ~
~
A Senior Management Review Team, a Restart Oversight Committee and a l'                                                                                    System Engineering Review Board have been established to oversee self-assessment and deficiency correction activities A number of initiatives were implemented to identify and assess plant programs and safety system problems including design reviews, system evaluations, and functional area assessments These initiatives have resulted in comprehensive system and process review that revealed problems that require resolution prior to plant restart
A Senior Management Review Team, a Restart Oversight Committee and a System Engineering Review Board have been established to oversee self-assessment and deficiency correction activities A number of initiatives were implemented to identify and assess plant programs and safety system problems including design reviews, system evaluations, and functional area assessments These initiatives have resulted in comprehensive system and process review that revealed problems that require resolution prior to plant restart
                                                                                    ' Appropriate plant staff has been trained in conducting effective self-assessments, identifying root causes and correcting deficiencies
' Appropriate plant staff has been trained in conducting effective self-assessments, identifying root causes and correcting deficiencies Operational Performance (Frequency of Transients)
                                                                    .:      Operational Performance (Frequency of Transients)
Overall, plant operation was good as indicated by the low number of plant transients and operational events Before the dual unit shutdown, improvements in the area of operations resulted in better control room command and control, more consistent procedural adherence, and higher quality operating procedures Operations performance during the Unit 2 outage was also good
Overall, plant operation was good as indicated by the low number of plant transients and operational events Before the dual unit shutdown, improvements in the area of operations resulted in better control room command and control, more consistent procedural adherence, and higher quality operating procedures Operations performance during the Unit 2 outage was also good


18
18 Human Performance Human performance exhibited improvement since the facility shutdown in l
      .                                            Human Performance                                                                           l l
September 1997-
Human performance exhibited improvement since the facility shutdown in l
~
September 1997-                                                 ~
Initiatives were implemented to reduce the number of contractor control and maintenance human performance errors The results of these initiatives indicated a decline in the number of personnel errors l'
Initiatives were implemented to reduce the number of contractor control and         l maintenance human performance errors                                                 ;
L Material Condition (Safety System Reliability / Availability)
The results of these initiatives indicated a decline in the number of personnel errors l'
The material condition of plant systems th.at operate routinely was good l
L
Subsequent to plant shutdown, safety system walkdowns identified issues requiring attention prior to plant startup Work Control System enhancements are being made to address process inefficiencies j
      .                                            Material Condition (Safety System Reliability / Availability)
i l
The material condition of plant systems th.at operate routinely was good l                                                   -
Engineering and Design j
Subsequent to plant shutdown, safety system walkdowns identified issues requiring attention prior to plant startup Work Control System enhancements are being made to address process inefficiencies j                                                                                                                                               i l     .                                            Engineering and Design                                                                       j L
Licensee reviews and assessments following NRC inspections have identified the L
Licensee reviews and assessments following NRC inspections have identified the breath and depth of engineering problems                                             ;
breath and depth of engineering problems Actions are being taken to address design control process bypasses that resulted in a loss of design control Initiatives including functional area assessments and independent design reviews are in progress to improve engineering support to plant organizations l.
Actions are being taken to address design control process bypasses that resulted in a loss of design control Initiatives including functional area assessments and independent design reviews
ARGUMENTS FOR INCREASING CURRENT AGENCY ATTENTION I
: l.                                                          are in progress to improve engineering support to plant organizations ARGUMENTS FOR INCREASING CURRENT AGENCY ATTENTION                                     I
Effectiveness of Licensee Self-Assessment I
      .                                            Effectiveness of Licensee Self-Assessment I
Historically, self assessments identified procedural adherence and adequacy i
i Historically, self assessments identified procedural adherence and adequacy problems, but missed the broader scope issues Initiatives implemented to address broader issues are identifying problems that
problems, but missed the broader scope issues Initiatives implemented to address broader issues are identifying problems that
                                                          - were not known by the NRC or the licensee Since the dual unit shutdown, the large number of identified plant problems is       ;
- were not known by the NRC or the licensee Since the dual unit shutdown, the large number of identified plant problems is challenging plant staff, the work control process, and corrective action systems Operational Performance (Frequency of Transients) l Both units have been in extended shutdown since September 1997 Several operator errors resulted in minor plant transients that were attributed to procedure adequacy and adherence problems Recent operator training failure rates and NRC identified weaknesses indicated tnat performance had declined I
challenging plant staff, the work control process, and corrective action systems
    - ..                                          Operational Performance (Frequency of Transients) l Both units have been in extended shutdown since September 1997 Several operator errors resulted in minor plant transients that were attributed to procedure adequacy and adherence problems Recent operator training failure rates and NRC identified weaknesses indicated tnat performance had declined I


4 i
4 i
  '^-.                                                                                                                                                                                 l l
'^-.
;                                                                                                                    19 l                                         . .                    Human Performance r                                                                -
19 l
Personnel errors attributed to the control of contractors needed attention Surveillance procedures need upgrading Material Condition (Safety System Reliability / Availability) l
Human Performance Personnel errors attributed to the control of contractors needed attention r
                                                                      ' Material condition of some safety systems had degraded to the point that                                     i operability was questionable                                                                                 ;
Surveillance procedures need upgrading Material Condition (Safety System Reliability / Availability) l
Initially, the NRC identified a majority of the significant safety system issues and                         1 NRC intervention was necessary to ensure broad corrective action was taken L
' Material condition of some safety systems had degraded to the point that i
Problems identified with the work control program necessitated programmatic                                   ,
operability was questionable Initially, the NRC identified a majority of the significant safety system issues and 1
!                                                                      . changes to improve efficiency                                                                                 l Licensee system assessments have continued to identify a number of problems that impact material condition and require repair or replacement prior to restart
NRC intervention was necessary to ensure broad corrective action was taken L
                                          .                      Engineering and Design l
Problems identified with the work control program necessitated programmatic
. changes to improve efficiency l
Licensee system assessments have continued to identify a number of problems that impact material condition and require repair or replacement prior to restart Engineering and Design l
Engineering support to plant organizations has not been effective:
Engineering support to plant organizations has not been effective:
L                                                                       =
L Calculations to support engineering decisions were weak or in error,
Calculations to support engineering decisions were weak or in error, j-                                                                       .
=
Safety evaluations were poor and could not be supported by existing documentation Numerous processes existed that bypassed the design control process                                 l The consequences of the ineffective engineering support and design control L                                                                       process resulted in questionable operability of several safety systems Independent design inspection of the containment spray system also identified
j-Safety evaluations were poor and could not be supported by existing documentation Numerous processes existed that bypassed the design control process l
,                                                                        design and performance problems                                                                               I g
The consequences of the ineffective engineering support and design control L
Actions to address the poor design control process have only recently been L                                                                       implemented t
process resulted in questionable operability of several safety systems Independent design inspection of the containment spray system also identified design and performance problems I
p                                   . The senior managers discussed NRC's inspection efforts at D.C. Cook and the design issues that had been identified.since the August 1997 A/E inspection. Of particular note were the significant material condition problems associated with the ice condenser, which led to the                                                 !
g Actions to address the poor design control process have only recently been L
plant's operation outside of its design basis and the extended shutdown of both units since September 1997. While overall performance in the areas of operations remained good, significant safety system deficiencies were identified during the period. In addition, weaknesses in the licensee's 50.59 and self-assessment processes were noted.
implemented t
p
. The senior managers discussed NRC's inspection efforts at D.C. Cook and the design issues that had been identified.since the August 1997 A/E inspection. Of particular note were the significant material condition problems associated with the ice condenser, which led to the plant's operation outside of its design basis and the extended shutdown of both units since September 1997. While overall performance in the areas of operations remained good, significant safety system deficiencies were identified during the period. In addition, weaknesses in the licensee's 50.59 and self-assessment processes were noted.
The discussions of the senior managers primarily focused on the risk significance of the
The discussions of the senior managers primarily focused on the risk significance of the
                                    - engineering and design issues identified at D.C. Cook. Specifically, the deficiencies associated
- engineering and design issues identified at D.C. Cook. Specifically, the deficiencies associated
                                    - with the ice condenser, the containment recirculation system, and the containment hydrogen abatement systems were of particular concern to the senior managers. The senior managers also noted that the performance indicators and LER data revealed a declining performance trend in the first quarter of 1998. The senior managers acknowledged the risk significance of the containment deficiencies and other material condition problems identified in the PIM.
- with the ice condenser, the containment recirculation system, and the containment hydrogen abatement systems were of particular concern to the senior managers. The senior managers also noted that the performance indicators and LER data revealed a declining performance trend in the first quarter of 1998. The senior managers acknowledged the risk significance of the containment deficiencies and other material condition problems identified in the PIM.
L                                                                               _            -      _ - - - - - - -    - - - - - - - _ - - ------------- - -------- _ -- - -- --- - i
L i


o 20                                         i The senior managers concluded that the licensee and NRC may in fact not understand the               !
o 20 The senior managers concluded that the licensee and NRC may in fact not understand the extent of problems at D.C. Cook. While it was initially thought that the problems may be limited to the engineering and surveillance areas, the senior managers decided that additional information was necessary before such an determination could be validated. NRC response to 1
extent of problems at D.C. Cook. While it was initially thought that the problems may be limited to the engineering and surveillance areas, the senior managers decided that additional               ;
the licensee's ongoing programmatic and functional area assessments and plant system i
information was necessary before such an determination could be validated. NRC response to           1 the licensee's ongoing programmatic and functional area assessments and plant system                 i verification reviews was discussed and senior management concluded that special inspection           i activities are warranted in these areas.
verification reviews was discussed and senior management concluded that special inspection activities are warranted in these areas.
The senior managers acknowledged that there has been a slow decline at this facility for some time and that, combined with the risk-significant engineering issues at the site, there is a need to communicate this decline to the licensee. Thus, the senior managers agreed that a trending letter was appropriate to convey the agency's concerns with D.C. Cook's recent performance.
The senior managers acknowledged that there has been a slow decline at this facility for some time and that, combined with the risk-significant engineering issues at the site, there is a need to communicate this decline to the licensee. Thus, the senior managers agreed that a trending letter was appropriate to convey the agency's concerns with D.C. Cook's recent performance.
Other Plants Discussed:
Other Plants Discussed:
Line 363: Line 427:
Quad Cities was first discussed at the June 1991 SMM and at each SMM since June 1993 with the exception of the June 1997 SMM. Following the January 1994 SMM, the NRC sent the licensee a Trending Letter to express concern over the continuing decline in overall performance. After the June 1994 SMM, the NRC sent the licensee a Follow-up Trending Letter expressing continuing concem. During the first half of 1995 overall performance improved.
Quad Cities was first discussed at the June 1991 SMM and at each SMM since June 1993 with the exception of the June 1997 SMM. Following the January 1994 SMM, the NRC sent the licensee a Trending Letter to express concern over the continuing decline in overall performance. After the June 1994 SMM, the NRC sent the licensee a Follow-up Trending Letter expressing continuing concem. During the first half of 1995 overall performance improved.
Following the June 1995 SMM, NRC managers concluded that the declining trends at the Quad Cities Station had been arrested. During 1996, Quad Cities displayed slow improvement in operations performance, material condition, procedural adherence, trending, and accountability.
Following the June 1995 SMM, NRC managers concluded that the declining trends at the Quad Cities Station had been arrested. During 1996, Quad Cities displayed slow improvement in operations performance, material condition, procedural adherence, trending, and accountability.
The last SALP period (report issued January 30,1998) found the conduct of nuclear activities at the plant to have declined. The plant was discussed again during the January 1998 SMM. The senior managers agreed that a trending letter was the appropriate regulatory tool to convey the agency's concems.                     -
The last SALP period (report issued January 30,1998) found the conduct of nuclear activities at the plant to have declined. The plant was discussed again during the January 1998 SMM. The senior managers agreed that a trending letter was the appropriate regulatory tool to convey the agency's concems.
The Unit 2 was shutdown on September 27, and Unit 1 on December 20,1997, to address concems regarding the ability to safely shutdown the units in the event of a fire. A Confirmatory Action Letter (CAL) was issued to the licensee in January 1998 concerning the fire protection (Appendix R) issues. Over the course of this assessment period substantial problems were identified with the procedures for 10 CFR 50 Appendix R Fire Protection, in service inspection (ISI) and in service testing (IST) programs, understanding and application of the design basis, operability determinations and 10 CFR 50.59 evaluations, continued missed surveillance testing, and untimely and inadequate corrective actions. The licensee has begun broad based corrective actions to improve these areas. AltNugh the effects of the corrective actions are not fully realized yet, much improvement has been noted. On May 22,1998, the improvement efforts culminated in closure of the CAL and the licensee subsequently began startup of both         '
The Unit 2 was shutdown on September 27, and Unit 1 on December 20,1997, to address concems regarding the ability to safely shutdown the units in the event of a fire. A Confirmatory Action Letter (CAL) was issued to the licensee in January 1998 concerning the fire protection (Appendix R) issues. Over the course of this assessment period substantial problems were identified with the procedures for 10 CFR 50 Appendix R Fire Protection, in service inspection (ISI) and in service testing (IST) programs, understanding and application of the design basis, operability determinations and 10 CFR 50.59 evaluations, continued missed surveillance testing, and untimely and inadequate corrective actions. The licensee has begun broad based corrective actions to improve these areas. AltNugh the effects of the corrective actions are not fully realized yet, much improvement has been noted. On May 22,1998, the improvement efforts culminated in closure of the CAL and the licensee subsequently began startup of both units. These efforts put a significant strain on licensee staff, and there has been an increue in employee tumover. There have also been numerous management changes since December l
units. These efforts put a significant strain on licensee staff, and there has been an increue in employee tumover. There have also been numerous management changes since December                   l 1997 including the BWR Vice President, Site Vice President, Station Manager, Engineering
1997 including the BWR Vice President, Site Vice President, Station Manager, Engineering


21 Manager, Maintenance Manager, and Quality and Safety Assessment Manager.
21 Manager, Maintenance Manager, and Quality and Safety Assessment Manager.
Operations generally performed well during this assessment period although there were some
Operations generally performed well during this assessment period although there were some
                                                                              ' equipment configuration problems, mostly due to errors by non-licensed operators, some of which impacted the reliability and operability of the emergency diesel generators (EDGs).
' equipment configuration problems, mostly due to errors by non-licensed operators, some of which impacted the reliability and operability of the emergency diesel generators (EDGs).
Operations staff was involved in several missed technical specifications surveillance through January 1998. However, much improvement has been noted in this area with no missed surveillance since February. Control room demeanor and operator knowledge continued to be good. On June 27 and 28,1998 respectively, Units 1 and 2 each scrammed from full pcwer.
Operations staff was involved in several missed technical specifications surveillance through January 1998. However, much improvement has been noted in this area with no missed surveillance since February. Control room demeanor and operator knowledge continued to be good. On June 27 and 28,1998 respectively, Units 1 and 2 each scrammed from full pcwer.
The Unit 1 scram was due to a failed level switch occurring while a % scram signal was inserted for surveillance testing. The Unit 2 scram was caused by an electrical perturbation due to severe weather.
The Unit 1 scram was due to a failed level switch occurring while a % scram signal was inserted for surveillance testing. The Unit 2 scram was caused by an electrical perturbation due to severe weather.
Maintenance work performance was generally adequate, with some exa'mples of deficien't work resulting in the need for rework. Although the plant material condition was generally good, there were repetitive maintenance issues. The emergency diesel generators were all rendered .
Maintenance work performance was generally adequate, with some exa'mples of deficien' work t
inoperable due to continuing problems with time delay relays. There were also examples of           I poor oversight of contracted work, and recurring examples of maintenance processes not adhering to vendor recommendations. The licensee continued to miss technical specification surveillance. As an example, the source range nuclear instruments on both units had to be declared inoperable due to a failure to perform the required functional testing. However,
resulting in the need for rework. Although the plant material condition was generally good, there were repetitive maintenance issues. The emergency diesel generators were all rendered.
!                                                                                  improvement has been noted in this area with no missed surveillance since February. In response to numerous deficiencies identified by the NRC in the licensee's ISI and IST programs, the licensee performed their own audit of the program and is addressing the findings by rebuilding the program.
inoperable due to continuing problems with time delay relays. There were also examples of I
poor oversight of contracted work, and recurring examples of maintenance processes not adhering to vendor recommendations. The licensee continued to miss technical specification surveillance. As an example, the source range nuclear instruments on both units had to be declared inoperable due to a failure to perform the required functional testing. However, improvement has been noted in this area with no missed surveillance since February. In response to numerous deficiencies identified by the NRC in the licensee's ISI and IST programs, the licensee performed their own audit of the program and is addressing the findings by rebuilding the program.
Weaknesses in engineering continued to involve the lack of understanding and application of the design basis, operability determinations and 10 CFR 50.59 evaluations, and attention-to-detail in calculations. Substantial programmatic problems with the application of 10 CFR 50.59 were i
Weaknesses in engineering continued to involve the lack of understanding and application of the design basis, operability determinations and 10 CFR 50.59 evaluations, and attention-to-detail in calculations. Substantial programmatic problems with the application of 10 CFR 50.59 were i
identified by the licensee following NRC identification that the licensee conducted a hydrostatic test of the reactor vessel and primary system boundary after core criticality in violation of 10 CFR 50 Appendix G requirements. The licensee has initiated several design basis initiatives and an FSAR review. Engineering has applied a majority of its available resources to resolving the fire protection safe shutdown issues. Some positive efforts have been noted in the licensee's ability to meet commitments and improve their system failure analysis.
identified by the licensee following NRC identification that the licensee conducted a hydrostatic test of the reactor vessel and primary system boundary after core criticality in violation of 10 CFR 50 Appendix G requirements. The licensee has initiated several design basis initiatives and an FSAR review. Engineering has applied a majority of its available resources to resolving the fire protection safe shutdown issues. Some positive efforts have been noted in the licensee's ability to meet commitments and improve their system failure analysis.
Overall performance in plant support, except fire protection, remained generally good and unchanged from the previous assessment period. The licensee allowed high levels of L
Overall performance in plant support, except fire protection, remained generally good and unchanged from the previous assessment period. The licensee allowed high levels of L
contamination in some areas of the plant and overall station dose was high. Other attributes of the plant radiation protection program were good.
contamination in some areas of the plant and overall station dose was high. Other attributes of the plant radiation protection program were good.
l                                                                                   In several cases, the licensee's self-assessment activities were effective in identifying problems, however, resolution of the findings was weak in some cases. The licensee properly detected a problem with mixing different kinds of grease in the station blackout diesel generator, but did not follow through in making an operability decision until questioned by the NRC inspectors.
l In several cases, the licensee's self-assessment activities were effective in identifying problems, however, resolution of the findings was weak in some cases. The licensee properly detected a problem with mixing different kinds of grease in the station blackout diesel generator, but did not follow through in making an operability decision until questioned by the NRC inspectors.
Corrective actions for previous EDG start failures were not tracked to completion. Also, problems identified at the Dresden station were not always adequately addressed at Quad
Corrective actions for previous EDG start failures were not tracked to completion. Also, problems identified at the Dresden station were not always adequately addressed at Quad


Line 386: Line 451:
SMM Discussion:
SMM Discussion:
The senior managers considered the following factors from the plant performance evaluation template, in determining the appropriate agency response to the identified performance concems:
The senior managers considered the following factors from the plant performance evaluation template, in determining the appropriate agency response to the identified performance concems:
ARGUMENTS FOR MAINTAINING CURRENT AGENCY ATTENTION L     =
ARGUMENTS FOR MAINTAINING CURRENT AGENCY ATTENTION L
Effectiveness of Licensee Self-Assessment l
Effectiveness of Licensee Self-Assessment
l June 1997 assessment of Maintenance Rule implementation provided a clear set f                     of major issues. Corporate assessment in 1998 was thorough and entire
=
;                    program was revamped. Maintenance Rule follow up inspection concluded all requirements were met.
l l
l-           -
June 1997 assessment of Maintenance Rule implementation provided a clear set f
January 1998 assessment of 50.59 program was thorough and identified programmatic breakdown. Improvement program was implemented.
of major issues. Corporate assessment in 1998 was thorough and entire program was revamped. Maintenance Rule follow up inspection concluded all requirements were met.
i Assessments of ISI and IST were thorough and identified multiple problem areas.
l-January 1998 assessment of 50.59 program was thorough and identified programmatic breakdown. Improvement program was implemented.
Improvement programs were implemented.
Assessments of ISI and IST were thorough and identified multiple problem areas.
i Improvement programs were implemented.
l Multiple Fire Protection safe shutdown procedure deficiencies were identified. All safe shutdown paths were declared inoperable and Unit 2 was shutdown early.
l Multiple Fire Protection safe shutdown procedure deficiencies were identified. All safe shutdown paths were declared inoperable and Unit 2 was shutdown early.
i Unit 1 was subsequently shutdown in December. New Safe Shutdown Analysis -
Unit 1 was subsequently shutdown in December. New Safe Shutdown Analysis -
and implementing procedures were developed.
i and implementing procedures were developed.
Quality and Safety Assurance organization has taken an active role in improving the performance of the corrective action program Operational Performance (Frequency of Transients)
Quality and Safety Assurance organization has taken an active role in improving the performance of the corrective action program Operational Performance (Frequency of Transients)
Good dual unit operation in 1997.
Good dual unit operation in 1997.
                ~
~
Restarts following lengthy outages for both units in May 1998 were carefully
Restarts following lengthy outages for both units in May 1998 were carefully
                    ' planned and controlled.
' planned and controlled.
Operator response to plant conditions in 1997 was good with complex evolutions handled well.
Operator response to plant conditions in 1997 was good with complex evolutions handled well.
      .      Human Performance Operator performance in 1997 was generally good, with transient responses, startups and shutdowns handled well. Operator performance during the restart of     j
Human Performance Operator performance in 1997 was generally good, with transient responses, startups and shutdowns handled well. Operator performance during the restart of j


l   .-
l
                                                                                                          )
)
l 23 both units in May 1998 was essentially error free.
l 23 both units in May 1998 was essentially error free.
Maintenance personnel generally performed tasks safely and in accordance with         j procedures.-                                                                           1 Good worker performance in Plant Support.
Maintenance personnel generally performed tasks safely and in accordance with j
        . Material Condition (Safety System Reliability / Availability) t Material condition was generally adequate and supported 2 long periods of dual unit operation in 1997.
procedures.-
1 Good worker performance in Plant Support.
Material Condition (Safety System Reliability / Availability) t Material condition was generally adequate and supported 2 long periods of dual unit operation in 1997.
I Maintenance backlog has been reduced and ability to get work done has been demonstrated.
I Maintenance backlog has been reduced and ability to get work done has been demonstrated.
l         -
l Permanent fixes to many of the known equipment problems were aggressively pursued in preparation for restart.
Permanent fixes to many of the known equipment problems were aggressively pursued in preparation for restart.
l Engineering and Design Committed to perform in-depth system design reviews.
l
        . Engineering and Design Committed to perform in-depth system design reviews.
An Engineering Assurance Group (EAG) was established to review engineering products and upgrade the quality of engineering work.
An Engineering Assurance Group (EAG) was established to review engineering products and upgrade the quality of engineering work.
Substantial resources were applied to the resolution of fire protection safe           j shutdown pathway issues. A new Safe Shutdown Analysis and implementing                 I
Substantial resources were applied to the resolution of fire protection safe j
!                  procedures were developed. The Confirmatory Action Letter was closed in May 1998.'                                                                                 !
shutdown pathway issues. A new Safe Shutdown Analysis and implementing procedures were developed. The Confirmatory Action Letter was closed in May 1998.'
Training and in-line performance of 50.59 evaluations by the EAG were implemented to improve safety evaluations. Appropriate, successful hydrostatic         1 tests were completed on both units in 1998.
Training and in-line performance of 50.59 evaluations by the EAG were implemented to improve safety evaluations. Appropriate, successful hydrostatic 1
ARGUMENTS FOR INCREASING AGENCY ATTENTION
tests were completed on both units in 1998.
        . Effectiveness of Licensee Self-Assessment i
ARGUMENTS FOR INCREASING AGENCY ATTENTION Effectiveness of Licensee Self-Assessment i
Resolution of 1997 self-assessment findings on Maintenance Rule was untimely and inadequate, September 1997 inspection concluded worst implementation in
Resolution of 1997 self-assessment findings on Maintenance Rule was untimely and inadequate, September 1997 inspection concluded worst implementation in Rill.
!_                Rill.
Assessment of 50.59 program and ISI/IST programs were prompted by several instances of poor implementation such as Appendix G hydrostatic test after.
Assessment of 50.59 program and ISI/IST programs were prompted by several instances of poor implementation such as Appendix G hydrostatic test after .
criticality.
criticality.
                  . IPEEE showed fire to be a high risk contributor and a large number of operator
. IPEEE showed fire to be a high risk contributor and a large number of operator


24 l
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Line 431: Line 496:
Extensive NRC intervention was needed for complete resolution of the issues.
Extensive NRC intervention was needed for complete resolution of the issues.
Compensatory actions were still needed.
Compensatory actions were still needed.
1 I.                                                                                          -
The corrective action program lacked rigor and thoroughness. As a result, I.
The corrective action program lacked rigor and thoroughness. As a result, identified problems were not adequately addressed and existed for long periods.
identified problems were not adequately addressed and existed for long periods.
l l-
l l-Operational Performance (Frequency of Transients)
* Operational Performance (Frequency of Transients)
Minimal operating performance data because both units were in an extended outage until May 1998 (Unit 2 shutdown in September 97 and Unit 1 in December 97).
Minimal operating performance data because both units were in an extended outage until May 1998 (Unit 2 shutdown in September 97 and Unit 1 in December         !
l O,:erating and operability decisions were weak in some cases in 1997, such as entering shutdown LCOs to perform maintenance.
97).                                                                                 l O,:erating and operability decisions were weak in some cases in 1997, such as entering shutdown LCOs to perform maintenance.
]
                                                                                                                                                                                          ]
l Human Performance Operations staff was involved in several missed Technical Specifications surveillance.
l
                                                                                          . Human Performance Operations staff was involved in several missed Technical Specifications surveillance.
1 Personnel errors, mostly by non-licensed operators increased slightly and some resulted in unintended changes in plant configuration.
1 Personnel errors, mostly by non-licensed operators increased slightly and some resulted in unintended changes in plant configuration.
Maintenance errors resulted in unnecessary radiation exposure and incorrect reassembly of seal ring type valves.
Maintenance errors resulted in unnecessary radiation exposure and incorrect reassembly of seal ring type valves.
                                                                                                  . Multiple weaknesses in system knowledge, understanding the design basis, and attention to detail in calculations hindered individual performance in wgineering.
. Multiple weaknesses in system knowledge, understanding the design basis, and attention to detail in calculations hindered individual performance in wgineering.
Material Condition (Safety System Reliability / Availability)
Material Condition (Safety System Reliability / Availability)
Preventive maintenance and corrective actions for electrical breaker problems was untimely and inadequate.
Preventive maintenance and corrective actions for electrical breaker problems was untimely and inadequate.
Emergency diesel generators have had marginal auto-start reliability.
Emergency diesel generators have had marginal auto-start reliability.
Several repetitive equipment problems have existed for an extended period.
Several repetitive equipment problems have existed for an extended period.
                                                                                          . Engineering and Design Design basis information was not easily retrievable or lacking in quality. Some calculations were missing.
Engineering and Design Design basis information was not easily retrievable or lacking in quality. Some calculations were missing.
Staff change out and diversion to fire protection issues limited the effectiveness of the Engineering Assurance Group.
Staff change out and diversion to fire protection issues limited the effectiveness of the Engineering Assurance Group.
1 l
1
                                                                                                                                                                                          )
)


(*
(*
l:
l:
25 l                       All Fire Protection safe shutdown paths were inoperable due to procedure I
25 l
All Fire Protection safe shutdown paths were inoperable due to procedure I
discrepancies. Unit 2 was shutdown from September 97 to May 98 and Unit 1 from December 97 to May 98 because of reliance on opposite unit equipment, incomplete Safe Shutdown Analysis and inadequate implementing procedures.
discrepancies. Unit 2 was shutdown from September 97 to May 98 and Unit 1 from December 97 to May 98 because of reliance on opposite unit equipment, incomplete Safe Shutdown Analysis and inadequate implementing procedures.
L                       Compensatory measures are still necessary to ensure cafe shutdown.
L Compensatory measures are still necessary to ensure cafe shutdown.
L Poor safety decisions, inadequate 50.59 screening, and poor understanding of the ASME Code led to hydrostatic test of the reactor vessel at power instead of prior to criticality in June of 1997, in violation of 10 CFR 50 Appendix G. The         ,
L Poor safety decisions, inadequate 50.59 screening, and poor understanding of the ASME Code led to hydrostatic test of the reactor vessel at power instead of prior to criticality in June of 1997, in violation of 10 CFR 50 Appendix G. The quality of inspection performed for the test was also inadequate.
quality of inspection performed for the test was also inadequate.                       j
j
    ' The senior managers noted observations of mixed plant performance since the last SMM. Both units at Quad Cities restarted at the end of May after a long dual-unit outage to reestablish
' The senior managers noted observations of mixed plant performance since the last SMM. Both units at Quad Cities restarted at the end of May after a long dual-unit outage to reestablish
    . Appendix R safe-shutdown paths. Subsequent to the restart there were several power
. Appendix R safe-shutdown paths. Subsequent to the restart there were several power
;    ' reductions and two scrams due, in part, to material condition issues. While operational l
' reductions and two scrams due, in part, to material condition issues. While operational l
    . performance demonstrated improvement since the extended outage, operations personnel were involved in several missed Technical Specification surveillance. Also, while the material condition of the plant improved and the maintenance backlog was reduced, there were L. maintenance errors and concems with emergency diesel generator reliability.
. performance demonstrated improvement since the extended outage, operations personnel were involved in several missed Technical Specification surveillance. Also, while the material L.
The Quality and Safety organization took an active role in improving the performance of the
condition of the plant improved and the maintenance backlog was reduced, there were maintenance errors and concems with emergency diesel generator reliability.
,      corrective action program; however, a lack of rigor resulted in the licensee's failure to address some long-standing issues.~ lt was also noted that the engineering organization appeared to be burdened by efforts to resolve Appendix R issues. The sense of NRC senior managers was that Quad Cities performance was mixed with slow improvement in some areas. While a decline in
The Quality and Safety organization took an active role in improving the performance of the corrective action program; however, a lack of rigor resulted in the licensee's failure to address some long-standing issues.~ lt was also noted that the engineering organization appeared to be burdened by efforts to resolve Appendix R issues. The sense of NRC senior managers was that Quad Cities performance was mixed with slow improvement in some areas. While a decline in
!    . some performance indicator trends was detected, the senior managers determined that there L   : were not sufficient operational data or inspection insights available to assess the overall
. some performance indicator trends was detected, the senior managers determined that there L
(     performance trend at Quad Cities. Furthermore, it was not clear that Comed's efforts had L     resulted in measurable performance improvements at Quad Cities. Consequently, the senior l     managers determined that it would be prudent to observe Quad Cities performance for a longer             i
: were not sufficient operational data or inspection insights available to assess the overall
!      period of time to assess the performance trend.                                                       -)
(
i The senior managers discussed the IPE and IPEEE associated with Quad Cities. Specifically,               ,
performance trend at Quad Cities. Furthermore, it was not clear that Comed's efforts had L
the senior managers noted that the IPE shows a low estimated core damage frequency for intemal events of 2.2E-6/yr. The IPEEE Core Damage Frequency was reported to be SE-3/yr                 l L     due to fires. . Fire initiators in the turbine building dominated the risk profi!S. While the licensee
resulted in measurable performance improvements at Quad Cities. Consequently, the senior l
:      has subsequently taken compensatory actions to reduce the fire CDF by 6.ddressing the fire               l l-   . protection safe shutdown pathway issues, long-term corrective actions are still underway and l
managers determined that it would be prudent to observe Quad Cities performance for a longer i
period of time to assess the performance trend.
-)
i The senior managers discussed the IPE and IPEEE associated with Quad Cities. Specifically, the senior managers noted that the IPE shows a low estimated core damage frequency for intemal events of 2.2E-6/yr. The IPEEE Core Damage Frequency was reported to be SE-3/yr L
due to fires.. Fire initiators in the turbine building dominated the risk profi!S. While the licensee has subsequently taken compensatory actions to reduce the fire CDF by 6.ddressing the fire l
l-
. protection safe shutdown pathway issues, long-term corrective actions are still underway and l
remain an area of NRC focus.
remain an area of NRC focus.
The senior managers could not conclude that the adverse performance trend had been arrested at Quad Cities due to the limited operational data since the last SMM.
The senior managers could not conclude that the adverse performance trend had been arrested at Quad Cities due to the limited operational data since the last SMM.


l4 i
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j-                                                                                         26 INDIAN POINT 3 Background Information:
j-26 INDIAN POINT 3 Background Information:
Indian Point 3 (IP3) was placed on the NRC Watch List in June 1993 as a result of a
Indian Point 3 (IP3) was placed on the NRC Watch List in June 1993 as a result of a
_performance decline that was attributedto weak management processes and controls, weak
_ erformance decline that was attributedto weak management processes and controls, weak p
                                      ' independent oversight, and a growing volume of plant deficiencies and operator performance errors. The plant entered an extended shutdown in February 1993 and did not restart until June of 1995. Additional material condition problems emerged, necessitating an extended maintenance outage in the latter part of 1995; The plant was 'again restarted in April .1996, and 3
' ndependent oversight, and a growing volume of plant deficiencies and operator performance i
L                                       has operated fairly consistently since that time, with a few extended outages to address some .
errors. The plant entered an extended shutdown in February 1993 and did not restart until June of 1995. Additional material condition problems emerged, necessitating an extended maintenance outage in the latter part of 1995; The plant was 'again restarted in April.1996, and 3
:                                      material condition deficiencies as well as a refueling outage from May to September of 1997.
L has operated fairly consistently since that time, with a few extended outages to address some.
Based on overall improvement in site performance and indications that the improvements would
material condition deficiencies as well as a refueling outage from May to September of 1997.
                                    . conti nue, the sen ior managers removed IP3 from Category 2 of the Watch List in June 1997..
Based on overall improvement in site performance and indications that the improvements would i
L l                                     . Since the last SMM, performance at IP3 continued to improve, albeit slowly in some areas.
h i
. cont nue, t e sen or managers removed IP3 from Category 2 of the Watch List in June 1997..
L l
. Since the last SMM, performance at IP3 continued to improve, albeit slowly in some areas.
Overall, the licensee operated the plant conservatively, and operational performance improved as indicated by fewer transients and forced outages. The plant operated continuously since the last SMM.' Human performance at the plant was good, as indicated by a personnel rate that was
Overall, the licensee operated the plant conservatively, and operational performance improved as indicated by fewer transients and forced outages. The plant operated continuously since the last SMM.' Human performance at the plant was good, as indicated by a personnel rate that was
                                    - maintained below the established station goal.
- maintained below the established station goal.
Equipment performance improved since the last SMM. Equipment modifications and enhancements contributed to fewer equipment failures and operator challenges. The service water piping replacernents and control room air conditioning modifications increased the
Equipment performance improved since the last SMM. Equipment modifications and enhancements contributed to fewer equipment failures and operator challenges. The service water piping replacernents and control room air conditioning modifications increased the
: respective system's reliability. The licensee made progress in reducing the non-outage backlog
: respective system's reliability. The licensee made progress in reducing the non-outage backlog by about 30E The reduction of backlog was indicative of improvements in the work control process.
;                                      by about 30E The reduction of backlog was indicative of improvements in the work control process.
Slow improvement was noted in the area of engineering. The engineering organization contributed to the identification and resolution of several design deficiencies. The licensee 4
Slow improvement was noted in the area of engineering. The engineering organization 4
. continued to implement engineering improvement plans and programs, such as engineering backlog reductions and engineering work process improvements. The licensee's motor operated valve program was cound and was an indication of improvement in long-term engineering programs, la contrast to these improvements, problems with equipment -
contributed to the identification and resolution of several design deficiencies. The licensee
L modifications and inadequate documentation of some operability determinations and engineering resolutions were sometimes evident.. One notable example was an inadequate modification which adversely affected the motor control centers that supported two of the emergency diesel generators
                                    . continued to implement engineering improvement plans and programs, such as engineering backlog reductions and engineering work process improvements. The licensee's motor operated valve program was cound and was an indication of improvement in long-term engineering programs, la contrast to these improvements, problems with equipment -
.There continued to be a good'self-assessment capability throughout the organization and a conservative operating philosophy. The quality assurance organization continued to make
L                                       modifications and inadequate documentation of some operability determinations and engineering resolutions were sometimes evident.. One notable example was an inadequate modification which adversely affected the motor control centers that supported two of the
~
;                                      emergency diesel generators
notable contributions to the identification of deficiencies.
                                      .There continued to be a good'self-assessment capability throughout the organization and a
                                    ~
conservative operating philosophy. The quality assurance organization continued to make notable contributions to the identification of deficiencies.
SMM Discussion:
SMM Discussion:
The' senior managers discussed the status of Indian Point 3. The senior managers noted that l
The' senior managers discussed the status of Indian Point 3. The senior managers noted that l


x 27
x 27
        - lP3 performance remained acceptable and continued to improve. The senior managers acknowledged that progress has been slow, but that it is continuing. It was noted that continued close monitoring of IP3 by the region will need to continue, but that agency-level attention is not warranted. The senior managers noted that IP3 will not be discussed at the next SMM.
- lP3 performance remained acceptable and continued to improve. The senior managers acknowledged that progress has been slow, but that it is continuing. It was noted that continued close monitoring of IP3 by the region will need to continue, but that agency-level attention is not warranted. The senior managers noted that IP3 will not be discussed at the next SMM.
l       Additional Topics Discussed:
l Additional Topics Discussed:
l
l
: 1. EDO's Ooenino Comments l
: 1. EDO's Ooenino Comments l
The Executive Director for Operations (EDO) welcomed the senior managers in attendance and
The Executive Director for Operations (EDO) welcomed the senior managers in attendance and
        - noted that there were some vital discussions related to the SMM process that would take place during the SMM. He emphasized that significant changes in the SMM process were likely in the coming year. He noted that Chairman Jackson had recently been inducted in the Women's Hall of Fame, an honor for both her and for the NRC.
- noted that there were some vital discussions related to the SMM process that would take place during the SMM. He emphasized that significant changes in the SMM process were likely in the coming year. He noted that Chairman Jackson had recently been inducted in the Women's Hall of Fame, an honor for both her and for the NRC.
2.' Chairman JacksormBemarks e         Congressional Activities The Chairman summarized the concems raised by the Senate Appropriations Subcommittee               !
2.' Chairman JacksormBemarks e
regarding the NRC's oversight of reactor facilities. Specifically, the concerns raised were 1) the need to end over-regulation,2) the need for the NRC to move to more risk-informed, performance-based regulation, and 3) the need to change the assessment process for reactor
Congressional Activities The Chairman summarized the concems raised by the Senate Appropriations Subcommittee regarding the NRC's oversight of reactor facilities. Specifically, the concerns raised were 1) the need to end over-regulation,2) the need for the NRC to move to more risk-informed, performance-based regulation, and 3) the need to change the assessment process for reactor facilities. The Chairman discussed her tasking memorandum recently issued to the staff to respond to these concems. The Chairman reiterated that this was an opportunity to call attention t
;        facilities. The Chairman discussed her tasking memorandum recently issued to the staff to           l t
to the progress made to date by the agency and to address concems that are valid. She noted that there is a hearing before the Senate Authorization Committee on July 30,1998. She also challenged the senior managers to reflect on whether the call for change represents a
respond to these concems. The Chairman reiterated that this was an opportunity to call attention to the progress made to date by the agency and to address concems that are valid. She noted that there is a hearing before the Senate Authorization Committee on July 30,1998. She also
)
,.      challenged the senior managers to reflect on whether the call for change represents a               )
L fundamental rethinking of activities or an acceleration of activities that are already ongoing.
L       fundamental rethinking of activities or an acceleration of activities that are already ongoing.
l e
l       e         Communication .
Communication.
l=                       .
l=
        .The Chairman discussed the recently completed OlG Cukure Survey and what the results should represent to agency senior management. Specifically, the managers should be                 !
.The Chairman discussed the recently completed OlG Cukure Survey and what the results should represent to agency senior management. Specifically, the managers should be concerned about the survey finding that employees believe their ideas are not valued by agency menagemen;. The Chairman challenged the senior managers to demonstrate to the staff that l
,        concerned about the survey finding that employees believe their ideas are not valued by agency
they are receptive to ideas. She also reiterated the importance of breaking down the barrier that l
!.      menagemen;. The Chairman challenged the senior managers to demonstrate to the staff that           l l        they are receptive to ideas. She also reiterated the importance of breaking down the barrier that   !
currently hinders the sharing of information between agency senior managers and staff. The l'
currently hinders the sharing of information between agency senior managers and staff. The l'       Chairman emphasized that the agency needs to improve its internal communication and benefit         i from the insights of a very talented staff.
Chairman emphasized that the agency needs to improve its internal communication and benefit i
e       ' Inspection Program The Chairman emphasized the need for improvements to the reactor inspection program. She noted that stakeholder are calling for changes in the way we inspect and for reductions in our inspection efforts. Agency senior managers will be meeting with these stakeholder on July 17,1998, to further discuss their concems about the inspection program. The Chairman noted
from the insights of a very talented staff.
e
' Inspection Program The Chairman emphasized the need for improvements to the reactor inspection program. She noted that stakeholder are calling for changes in the way we inspect and for reductions in our inspection efforts. Agency senior managers will be meeting with these stakeholder on July 17,1998, to further discuss their concems about the inspection program. The Chairman noted


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28 that the agency has already embarked on initiatives to improve the efficiency and effectiveness of its inspection process. She challenged the senior managers to ensure that as the inspection
28 that the agency has already embarked on initiatives to improve the efficiency and effectiveness of its inspection process. She challenged the senior managers to ensure that as the inspection process changes, it remains linked to safety. In order to do that, the inspection process must l
;                                                                                            process changes, it remains linked to safety. In order to do that, the inspection process must l                                                                                           become more risk-informed. . She shared her vision for a risk-informed baseline inspection process.
become more risk-informed.. She shared her vision for a risk-informed baseline inspection process.
* Performance Assessment Process :
Performance Assessment Process :
The Chairman challenged the senior managers to continue with its efforts to improve the reactor performance assessment process. She complimented the staff's efforts to date to utilize more objective data in the assessment process. She noted that the staff's IRAP initiative was an exemplary attempt to revise the assessment process and is a product upon which to build. She noted that the Commission recently approved SECY-98-045. However, the Chairman reiterated that the assessment process must become more risk-informed and must be more consistently implemented. The clarity of the agency assessments must also be enhanced. The Chairman shared her vision of the reactor performance assessment process and how the public (industry and general) perceives the safety of nuclear plants.
The Chairman challenged the senior managers to continue with its efforts to improve the reactor performance assessment process. She complimented the staff's efforts to date to utilize more objective data in the assessment process. She noted that the staff's IRAP initiative was an exemplary attempt to revise the assessment process and is a product upon which to build. She noted that the Commission recently approved SECY-98-045. However, the Chairman reiterated that the assessment process must become more risk-informed and must be more consistently implemented. The clarity of the agency assessments must also be enhanced. The Chairman shared her vision of the reactor performance assessment process and how the public (industry and general) perceives the safety of nuclear plants.
e         . Senior Management Meeting Process -                                                                                                                                                                                             )
e
. Senior Management Meeting Process -
)
The Chairman noted that the Commission, in its staff requirements memorandum issued in response to SECY 98-045, directed that SMMs be conducted on an annual basis in the future.
The Chairman noted that the Commission, in its staff requirements memorandum issued in response to SECY 98-045, directed that SMMs be conducted on an annual basis in the future.
The SRM also directed that the results of the SMM be provided to the Commission for negative                                                                                                                                                 ,
The SRM also directed that the results of the SMM be provided to the Commission for negative l
l                                                                                            consent. Finally, the SRM directed that enforcement not be the prime mover of the assessment                                                                                                                                                 '
consent. Finally, the SRM directed that enforcement not be the prime mover of the assessment j.
: j.                                                                                           process. With respect to enforcement, the Chairman noted that the agency's assessment process must be safety-focused and results-based.~ While enforcement is an important input to                                                                                                                                                 ,
process. With respect to enforcement, the Chairman noted that the agency's assessment process must be safety-focused and results-based.~ While enforcement is an important input to assessment, the assessment process must take a broader look at licensee performance. The Chairman reiterated that the change to annual SMMs does not preclude the senior managers from meeting more frequently, for example, to ensure the inspection and enforcement processes are being carried out consistently. She stressed that the decision by the Commission to require negative consent on the SMM results in no way reflects a lack of confidence in NRC senior
assessment, the assessment process must take a broader look at licensee performance. The Chairman reiterated that the change to annual SMMs does not preclude the senior managers from meeting more frequently, for example, to ensure the inspection and enforcement processes are being carried out consistently. She stressed that the decision by the Commission to require negative consent on the SMM results in no way reflects a lack of confidence in NRC senior
. managers. Rather, the decision reflects the significant importance of the SMM assessment results and is a step in enhancing the scrutability of the SMM process. Furthermore, the Commission has historically had a de facto option of changing SMM results as demonstrated by the Commission's 1996 decision to change Millstone from a Category 2 to a Category 3 facility.
                                                                                          . managers. Rather, the decision reflects the significant importance of the SMM assessment results and is a step in enhancing the scrutability of the SMM process. Furthermore, the Commission has historically had a de facto option of changing SMM results as demonstrated by the Commission's 1996 decision to change Millstone from a Category 2 to a Category 3 facility.
_d
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  . _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _                    _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ . _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _                                _ _ _ _d


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                                                                  . Senior Management Meeting Watch List -
. Senior Management Meeting Watch List -
t Removal Evaluation Factors
t Removal Evaluation Factors Clinton Crystal River 3 Dresden 2 & 3 LaSalle 1 & 2 l
,                                                                                                Clinton                                                                                                                                                               ,
Salem 1 & 2 1
Crystal River 3                                                                                                                                                             I Dresden 2 & 3                                                                                                                                                             l l
LaSalle 1 & 2 Salem 1 & 2 1
f-i
f-i
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)
I
I


ot r
lapgaed ai iws v s t
sd      s               r t a e lapgaed            aiv              .
r s
ne sd e              ieh       h ell n nd a hh co          n T, et Eml    spdldp e rdeec uro      ht Tl t
s r a e ot d s
s ge a .d et c ar io eo si it i
ieh h ell n nd a ne sd e r
et et       eh r r n s)    nEgwl u Ssmac
i hh n T, et eec ht Tl e rd o c ar io eo si it co s
                      , e ooine        h nv e imti r ash   n ua iaa e nc FcP     u    eFn    ass o
et et eh Eml d t
As ct st Ss                             et svegdl               i (      h se c er s       I       as nan aawi              nih i
ur
cni ison             neer         cdon t
.d et c s) u spdl p ge a r r n nEgwl Ssmac imti r ash nv n ua u eFn o
ef                                           iahc      o          r T
ne e
S n
ass
e        h l
, e ooi h iaa e nc FcP As ct st i
e     wlpt is s
h se i (
ol c r  a t  nt nen   u d  nTnjapae t
Ss et svegdl c er s
mgn syeie e ih el g ci sne.l I
I as nan cni ison neer cd aawi nih iahc o o n t
y m                      r v l e                                               no I                            l L             b eai             t         F v        eek r aieocn ,i*
ef t nt d nTnjapa l
T   m               e       s r s        De s n     c pt                    nt i
wlpt is ol T
N   o       d s           mntan            e        amn dDix      t cEioc   o r a C         ienmese                      h                   e t ed rmoeime t pf   i A            f e uh eic it              erl                        cei f e pod ei ri        t L               nl ic )s r b             t P              e            pAeE           oio w b ntsn    sF dan      r e n mEm.h                   y cre o ee t rf d                      t  F                         yi n nioi   d M             ioF           o sd P         lpep  s       vd n aiS)VlaI it E               nfrPcmne                                                         .d m L               e         (                   ed    ei  sh ne aFP sne B               ed e ale ahg bn csb y t
n r
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h e
e     a nior a n r
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                                                'er ar        ao inSviss          uc or R
e t
P              v seh pmi n a    nl c t    e g m gtcvr pri e moeih  (n n s ep s     oior aao l
s c r e
t r nr hi oeid    c h ieme                                                        o E                                             e p o pl                   hd h f r itaeetof H               scxwf t
syeie I
um i s       ic n n nr t    a  s e crfi                y eeE                     e               o e e pi f pi e a T              upr9 8t                            o l
e ci ih el g l
t nEl         p   eieivud i mnd           r     d M               ss sn          o9 iPi d eFm     h ct kt cess ne o dea                        -
mgn I
NO              iiF1                          Tat a aSiaVcimt                              o OR T F I
m y
AS TT     e SN     s n
r v l e
RA L   o p
F v eek sne n o
EP      s WF    R e         s                             s                                               1 O O               e                             e P               Y                             Y L
.l L
NA OV TO NM I
b eai t
LE CR                                               n R             d o
r n
e                           it O              s                             c a
r s c
F              s S              e                            e
aieoc,i*
_                    s                             v R               s                           it O               a                             c T             ly                             e r
T m
r C             h g                             o A                                             c d     u F         e   o                           d st         r                             e N   r c o er      o                          in O
e i
h t                                       f
s mntan De pt nt s n r a ienmese e
-    I c r     t e
amn dDix N
T    a o        e                           dd.
o d s t
F C         r a                           ly p   e
o cEioc e
. U    nd        s                             r o
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_    L   o n       a                             al
f e uh eic h d t pf i
-    A   it a
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a   e                             eev V        d     r                          lc e E   he s f i
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a e                          dd n n
it ic s t
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r e
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b b nt sF d r n t
m r
nl pAeE r
vb iss e
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s f o                            na u   r                            eh e                          h C
w sn an e
a    p                            em r
)
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t rf e mEm.h ee F
o   a e
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mg o                                 o or
y e
_            R    W                             Cp 1
vd nioi d
M ioF o sd P t
s n
aI lpep aiS)Vl it m E
nfrPcmne ed ei e
sne sh n aFP
.d L
e
(
B ed e ale ah r
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smomnb iss r
t O
bn csb y g
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v seh pmi e g m gt e m (n n s ep r pri R
e r
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it ia r soa         eccgse se               p u n r l
ms, umsuo ptoo it ia as e b
cc        n h at          mY a
r n
gcegur enr                                          ee        oEwau          eC oaeianu
mY h at ecc e p
_          r                                  sso             r r   piFl           l t
l cc soa se r
o af             os       t Fa         pr o
ee oEwa eC n
r o hde        celuP                      et e o s Dve gr rpnpt    acvtac            t p                     ct                           e s,s                     Sr a nl ot so ohi do o delua  ed h se er 'eethe ully eu a
a enr gs u
ri o e ar s nr l
u gcegur nu sso r
_                                          t ad o           t cq et cperei                                          er                        n cel             vgu e   nt s of           ih t i lu no e s   v   c a eh                                                               n lohcce              oo r r s e       c ee r                                                  st t
r piFl l
n  e al    ph saia                 las u        r                                 nu r
t r
_      e   se       t           t cw                          ppi      sis    e m detcn  ivndsf i n retnred                neo             me ,eo nb l
af os o o oaeia o hd celuP Dv et t
wfo ol m                          r ar        egs ene            io mohn pt o                di t o
Fa pr e
t aee ad e               oh       b ar                    oi t f es n t
gr cvtac r r t
t n it r esd mc                                                                     uu i r                                                 t C inob       s a plain                e vgn rd          s sac or s                h nnise         a           sde s e e dn qi ct on          iuid          a na
pnpt a e
-                                                                      f oi it echn h t
o s e
_                                  e                                    t dt
Sr p
_        htahsiyl  nevr ae eidn            h lo d sa ep id t
ct d ed e s,s e
ce al t n pd e
a ot ohi o l
t d     e nip a e , o s.
nl so d
t ee acf aie                                              uisnad                ic evh etf ineh      r e                              e s e aa d                 ai cr so    sf    evt    sn            r el e    n     e sr e uede                 mt  n oev vet io epse nr esist  d   eoi   t.
elua h s e 'e h ll cq y
u swd n essmtev e
eu o
i ea r   t lcmct i i oiy lt,t neo l nn      e o y ca r              ic vionea gS e ce so an h
t t
e or t        etnuemi pniesu           ec a t t n Hl tni  ev  l h   h in gsmrnley
r et u a o e ar s nr ad o e
                                                                              . mr      hs it ti t nstnmtsreqvi                    iet . et u s ee plt c                              nr
ri et cpereilu n e cel er e s of n
_        le i i    o reri e s a bsr e oi f t  icr     ai ice     o ec ccmn ua ht rt n                    pn  e f
o loh e vgu nt ih s
f u e t f r sf uo  r h o lt r ooe cR nnieC            es h e t
v c a eh n
cueos umd N    WacdcAsii                         Sr sc             Apccb eN r                 TR O
st r
I T
e al cc oo s e ee t
A
t i ph saia las r
_  T  e S s n
n r
R o p   o                                 o s N                                 N W e /
r r c
s
nu sis e e
                                          /
se cw u
s                                                 2 O R   e                                 e               o                         o P   Y                                 Y                 N                          N N
ppi t
O T
t l
N   t n                                 y e
nb wfo m
I L                                        r C     v                                 r a
d vndsf ed neo me,eo ol i i n et n
e r                                  c
etcn r nr r egs i moh pt di m
-          p                                                                              n
aee ad e r a ene o
_                                            o                                          e t
o t
o                               t s
t oh t
is                          e s                                 e               m                         b e                                 c r                a                         s r
s n t n oi esd mc b ar t
u                                 u .             r g                         a os                                        h s                                                   o a
o i r t f e uu sa or s h
e                                 sm ea r
C it r
p e
rd s
c m
c inob s a pl n e
r r n                         n t g                                           a s
ai vgn nnise a sd ct e d iuid f
t n                              ier no            io t                           m r  e                              icp                c                         r o
s e n qi e a na oi it ch h e
i a
on t
-    t c ic                               f f      n           e f
t dt n
r
h lo ah ne a id n e d
.      a f
e a t
f u
t d
uo st i
v eid ht siyl r e sa e ce e pd n nip p
i v                         e p
al t t
F   s                                       c         t c                         t n   e                               de a                e                         n
d uisna ic ee acf aie e, o s.
_      o d .                               t e                 r r
e aa ai i r e evh etf neh n cr s e d
                                                                    .                    a it  us                                 av ci               o de                      lp a lcm                                     t ct
mt r el n e e uede n
-      u   ne                             loc    e         t n                        lu f
so sf evt s u v v i n
ae la     l lar                                            s v isb                                       r hm                          s E
smtev ea e
ip t
o sr epse nr d eoi.
no o r h
swd c e
so ac e
oe et es i
t dle iep e
r esist t
c c .
tnn e
cf                             t g                                           ud ao                                nn f
vione so lcmct i i oiy
isi   m                      se e                                  e mra ve
,t neo r o a
                                                                                            ,t d ra t
ic a gS e c an l
aly cn                            eg
lt y
                                                    -          st  n                      et s t
e e or etnuemi Hl e h in. mr hs l
ice                                 gn             ise                         n n r
pniesu ec e. et gsmrnley it i t
er                                 ao                   i iao r u                               nl             Cifc                        t sm oc r
t t
at             Rf u                         ue Cr e                              Mou              Ns     .
a n
Sd
ni v h
t h
eqvi i t t stnmtsr t
nr f
c u s plt ua le n e oi ee ht rt n b pn icr ice o e ccmn o eri t
ai i i r e s a sr nnieC es t
c f
t f r h
f o
e u sf r r ooe cR h e cueos umd e uo lt WacdcAsii Sr sc Apccb eN TR N
r O
I TA T
e S
sn R
o E
p o
o s
N N
W e
2
/
/
s s
O R
e e
o o
N P
Y Y
N N
O T
N t
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e r
C v
r e
a r
c p
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t is e
o t
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s e
m b
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a s
r r
r a
u u.
g h
s os o
a sm r
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e a p
c r
n m
r n
t g a
r e
ier io t
n o m
n t
s c
r o
i icp a
o f
t ic f
n r
f e
e c
f uo f
i v
a u
st F
s c
i p
t d a c
t n
e e
e na o
d.
t e r
lp r
d us av o
it ci e
a lcm loc ct lu t
u t n ne lar ae s
l e
f la isb r
h m s
vE n o so t
e o
ac dle r
c ip h e iep c.
t m
ud cf t g f
a o n n e e e a isi se t
,t v c mr aly a
d r st n
eg n
et s ice gn ise iao t
n r
i n
er ao c
r u nl Ci sm t
r f
o c at Rf ue e
u u
Cr Mo Ns Sd


d e     cGfof       r  ei c
I.h ne e o
iss anat    yl,ceeor                emcnHo e
r nl cGfof d
at o 4, b puw e   esh                                                b e t
s nat o emc o c
_                                                              yf i e    f         h c                v ra .
e esh is e
ot v veTla                  eo ymdind . s                                                        vr us it                                      t fe eeln eit it
ei a yl,cee e
-                        i nii nt nr nepo uin    e xien e an anraloi avdt sit i neni    ct n
nH r
                                                                                          . p h
o 4, b puw yf i e h c b e t
aps          nt se erh                            t            aoef e n   f e   Imam ve c ys be pf   ot lplpd t
f at ot v eTla v a.
s n
ymdind.
e eo v
t r
aesah po sr  e e ad en  eyr a  te dct hi eia yef metse f nig o nb ss l
it v
t oisbi anot e noc i e s.
eo us e
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. p vr t
                                                                                                          .t i s
it s
m             hht entsf t
f eel niinr e xien avdt ct n aps n i
dnv e eo           r aiss ainne t
uin nepo si i neni h
v rS o            Qa opec                                                  f e heh
s e Imam nt e n nr oi aoef e n e
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t erh a a al e ct metse c
eh             g
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s9 0 ve      ef vo r
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est a inime ee erh e nnesfse f
po n ey f nig o nb s aFae t
pt f f d o o onat yo t
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m sd en s
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est t
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-                        t n
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l h
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t ef s pl at t
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c yf elyd h n eWiopact nAi n
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c s
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e sen o
on
t t
                                                      ,f       e egemp       msmivt    stih e eto ivm nmr yicsnr ai                      i      snv elo n cg niol                              t r cono nl eoa                 cie t l e d         rb eoo eu ae sit       t sd i
si l
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r b d oest m.epmmoi n nh a a et t r e r e eSan t
sc                       i t            f L ni m pdecon e      r                 f eee N                      t                         t                            ace         Epb p
e mb alp e nh pi ypt mI e a e
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r it e yni v
s                                    /
sv panc aot at cv s
s                                 /
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,f e
e et rone egemp o
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i nl eoa t l d rb eo eu cono cie e
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et C
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it t
pfo ur ae                                   ply                                 oe ub                                   oe                                 r p m   lae                                     pm r                                  gf e       v v                                   pi   t                          t o h
n o n r a s
t A         ea                                   aa                                  gt   s c    d h                                     o in                             isn s
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ae ply ur oe ub oe r p r
t c     n       oi                                 f t                                 osn a                                                                                      ye se t
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A ea a a gt s tc d h o
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v t
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_            d o me                                      sm s                                  sd c an iy ge et  i ad
r i
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r v
ose    oe                                      aa                                  umi e f
m l
rf                                                                                     t ImR     Pe f
ae o f
Sm                                  Qis  t 1.
lee es en uer f
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1
1


,                                                                jIllllllIjlll                                       1 I t
jIllllllIjlll 1
o                             t     t s
I t
s t
o t
n r
e se o
w ll e
n f
e A
h am sv t
f aa e
se n
t h pa h
wh soh n h
ic y
t e
e t
s psda s leye sT ei e
r e vl f icw v
o e n f
u gedma.
oVd ad f
oga e sr s
i Gasa dodeeh 8 er e h n r n r
n t
v v
r a o e a oO9 t
h n s n r ol er 9
aio ef it co aP h it ppE r
dt i e 1
n v gfaa Ae n e sh emC,
o e n at t g d
.t t
un c p
n r
n r
n e                         se        o       w                    ll e
6 rSi ns c eg e
sv        t am      f f        e n
o y
A          h aa        e y               h pa    se                                  .
at e i
t
a t
_              wh        s                soh n    t        e                    e        ht psda                        s    leye sT      h                    ic      ei            e       r u
u fh puuOeh ly c er c
oga e ne                    e vl sr gedma            .                    foVd f
Mnp de c
icw              v ad f
eso nr p csrEhTu h e t la x laTv t
o s
e s
r n        r          i dodeeh                8                        erol ev            h n Gasa it co h n s                aP h er t
a e ue cihCr
n r e a oO9    v 9
.J np oye ic s.
t aio                  refa iton dt                            .t ppE r
lar n t
nv              gfaa un itcg en 1
t os ad ef tn wmr e es
d e eg sh remCe 6,                            o p e n rSi at ns t
.i iv pt n
c Aec nfh  u a            t puuOeh ly i
t ynd Pfoe e
o c er       y        at e Mnp denr  p    c           eso csrEhTu                                           h e tnpla xe s   a e os  ue             cihCr oye .J t
e o gh sieht ri t lanio m
laTv ic           s .             t wmr       e t                                  t n                          ad                                                  .i lar n
f r ot vSt aiuToic m
_          e   e o gh                     es ef ivri sieht t                         pt ynd              n Pfoe f           r ot                         tapat lanio haiuToic m
i t
i vSt      t t                                                           ds        m e      hf                  nss .p pf       r e                                       a   nge m
r e apat ds t
o R s. is  g os            meiEp d
h ns
f e                    eens      t t aia  ng C    r  wrt                aieFu1                                       vh       a e       t n
.p pf e
t en a  e eivfe  ec            t eghPsrt s e n t                                .
hf a
htat lph a                e ea lcurey v ofe            t in ns sh  s e 'n bese mms                    t odh et a
nge m
t dmm is se t e             esere t io u el                             net             s    e u r N9eh e 5.f  a mrdtotani      r     t r y a                   s ec aae t t             r Pr os u
R s. g o meiEp eens aia s
h0st t
f t t ng o
eda gd      dtne po 'PseB  r                     oo oi i
is s d
t e   en t
e aieFu1 vh a e n en t
t 5       u o b e.         aa n       o     rI     ii s e              dl lsi v r      eac    t   i cme ayt hi e n t        a t
wrt C
at ot tmo    c sh l           a r
t ra e e c eghPsrt at lph e ea e n ht eivfe v of t in s
e ras          a   Vuo r nt t ladion      i         mde deime ad           e  h                 w o st y i
t ts e 'n bes a
odr s
t t
wt amht on cC t
et dmm lc e e
duaims fieqmo                                                              Pced  en a         ieo nt     t r
ns sh mms odh a is se e
eimodnui t             t    n s                                       ecc it    g n pt e           nm     n c el s rd ui o         Sua emedcCnoO                                                                 r i
ur y es e io t
nn eieme                                                              ioost insey                 enndt d o e o d.
u el net e u r t e er r y t t N9eh mrdtot s
idbch                  h oenot nE TcbavaaC i
r u
l e r a         h oo
ani a s aae o
-    N                                                                          i l     rPd           Tcc O
a ed dt o seB ec i
I T
Pr s t
A T  e s
e 5.f t
S  n R   o p                                                                                             o s W   e                                                                                           N
r t
                                                                                                      /
n r
R                             s                                          A                     s         4 O                              e                                          /                     e P                             Y                                           N                   Y N
oo oi en h0st gd a v
O T
e u
N                                                                            t s
aa e p 'P s e dl lsi cme t
I L                                                                           h g
5 o b e.
n o
rI t
i t
r eac Vuo ot mo sh l e
ii ayt t
r r
t n a at as a nt t c a
hi e t ladi i md ei ad h
w i
r s
on d me cC o st y odr e
n duaim wt amh t
e en a ieo t o Pced nt s
fieqmo t
eimodnui t
n s t
r ecc n
i s rd e
nm c el ui o Sua g n pt iteieme emedcCnoO ioost dt r nn N
idbch TcbavaaC insey enn o e o d.
h oenot nE i
i r a h oo d
e l
rPd Tcc l
O ITA T
e S
sn R
o E
p o
s N
W e
/
O R
A s
4 se
/
e P
Y N
Y NO TN s
I t
L h
sle r
sle r
C                                                                                                  e v t e is h
g e v C
t                                                  r e                   sll ol c   ly                                             v                 f a
is sll t e t
isr  lu e   .
r h
om t e dt na e  f                                              nl b               a d c
e ol f
v   e r n                                           e   o             no O     aa                                           mr ep                   oot d      smr                                          gd                 c sr it n
c ly v
a    mo                                           an                 eed n
a is lu om dt f e t e na re c
af r eep                                          na a
nl a
ir dn s
b d
v e n e
no r
o O
aa mr oo d
sm ep it t
c s gd r
r n
mo an iree a
af na d
r n
ee a
dn s
p mn gu o
t s
r i
r i
t o   t t
t o
nd mnso                gu ns o                      a    ee                                            ei                 oi t
a nd o
c                    iz     mvo t t aa                  rt ts a a                     n                                                  r r F                       a   er gp                                            oe pp                  st h
ns t
a                                                                      ec n
ei oi t
o                   O r
iz ee t t rt c
am ni r
a n
o o ct n di ih a g                                                              vt it a
mv aa t a o
u t
r r s h F
n   mn                                           ea                 o rk e
a er oe st a
l                        e   t v i
gp pp ec am n
vlp                pr a
r r o di o
v                      m   n   e                                       it cn m
O ni o
o .
ih a
e                                                                     a wn ai                                           ei E                       a   lpc h                                        f   t                         o e n f                    e yi d a                                                 e                 t t
ct vt it t
a n                                                                    t t fez a   no at                                            sm a                  na i n M                                                 h ev n      .       es e d ede                                                              mr ga e e t
g n
at ri t eloo e vi               e      ar s v s         t        gleo n o r om p                                             nil nu              ace e o r m                                           ed os              nuh ic Li m oo Cc                                           i cne Lar ant Mai n l.
a n
mn ea o e rk u
e i
itvlp pr t v l
m n e cn m wn a
o.
v e
ai ei h
E a
lpc f t a
o a
n e yi f
t n
d a e
t e
t a
e t f z a
no sm na i at a
n M
h e.
mr g es a
ed v n e d e
eloo e ar t
e e at e vi gleo t
s v ri t
s nu n o om r
p nil ace m
ed o nuh e o r
ic s
ant m
o o c n e n
Li Cc Lar Mai i
l.
l I
l I


i   )j   jl lll]1                   jjI                 j!)l s
i
                                                                                                                . n
)j jl lll]1 jjI j!)l s
_ ..                                                          de                                             r ia ta eh                               t r
. n de t ia r
ed e            y                       t t o g                                aet           m                     _
eh tr a
he               a                                                           sths    err e t
ed y
t                                       n n                nd
o aet m t t hs e he e a
-                  t a
g nd st er t
oc n  ctnd                                nit l               en            e r s             s
n t
.                .t   ia egndnmwdr eo                            en eerbn     iae a                0l a      t o n   o n                                              bmt             eeio              5l t         i oi nieetgact t         e o se avtat a                       3 ent              c yitr aiat r
t a ctnd n
sn          or    r a alpmhn                          0we          na ewh       anaf e h                                   r     sig v nt ma s np                                           mds e                       ear       t
nit l e n e s s
                                                                                                            ,ei n e m me      eo t                                 t ein                                              n eo i
r oc n eo en iae a r a o n
f        nt me an p
.t ia egndnmwdr eerbn 0l t o
a nps n ode       ht       erd                                             el         hla s e t eidt abtnt        nl         e                 ms evmp                        Cpe cui ddsnl terar eiPr o   ea                     eeiemd                       .
e n nieet e o bmt eio 5l t i ent gact 3
s vgs vi l
c oi t
s           y             pmi c                     oa          n              e l
t sn r a se avt 0we a a
ais t
yi aiat or alpmhn r
n   awPl croeagngu                    n                 rt           eront               uhse nT          im e               b e. s e                             p s h             plan                       n o m
at n
i nf u      ct           oam                       myempa        r             r    a .o Mno s ds nVnationinm                                             pifoa r i l                                                                      _
r ewh anaf e h
r m   me              hr aa o                        ea                                                                       _
sig r
cemic                              aie n o                                                                                 w C    me     rt oscemc obin o ophyer s
t v
                                                .                n a e coahmigi s t  t              t t gtaaa      r nSt n        s co emtt fi          o cl ic                    mh                                             eon t s               ss      i t
ma s np mds e ear n
n    r nlsS ea noha       ene r
,ei nt m m e f
n i mr e oina e vvi                        e e ci e   ea l
t t
e                       wlci                  f r                                 m       wnc t
e o n
el yargot t
nt m p
behnt  vt niugndf c s           i c
i ein nps e
pnpo     l eit     i a    ePcp ooe    .                       _
ode ht erd eo an a
ea r,s eosdine                                         o e sh epsn r           l p             ,sd                     _
e n
r nru ad vher                                                                               monEne o                                                oi h n e pi n cdse a      sve                                      mit dl ct n                     it           Fit f e nc                 oeen                    ,e       s ilnPolp                            _
el hla s t eidt nl e
sow               adn on e mewia                             seia  sh dnem l                  i l
ms e e
at i
vmp Cpe c abtnt ddsnl o ea eeiemd ui er eiPr vgs vi ais s
o                                                                       CCsrem aHmesoam t
l l
hgeWol n                     e   R roe'e b oc it u v ut                                                                                                                      _
s t ar y c
idc v ef.s ,edcr or sdt eo                u   c           i     do       Nf sm                                   _
n awPl pmi oa n n
ar                         hoi .             derp              e n nu e l
rt eront uhse e
i pf     aaedn t
t b e. s e p s h plan nT im e
pf                                  Enh dxn iEst      t a ahs-rdt     ep a
croeagngu myempa a
xe r
.o n
t l
i o
Ath PcsieFocm                    haenbl T pliAt       c        o
m nf ct oam i l r
      .N                                                                                                                                 _
rr s
O I
nVnationinm Mn u
T A
pifoa o s m
T  e s
m e hr o
n R o                                                                                                                             _
cemic r
_      E  p                                                                                                                             _
d aa ea w
s                                                                                                                             _
aie n o
W R e
rt t
o s      _
t t me oscemc.
O                                                                                          o P                                                     N                                 N N
n oah t
_      O T
s gtaaa C
N                                                      t e
obi o ophye n
ni d I                                                                                                   .
a e c s
L                                                                                             d C                                                     law                                eo r                                     _
r gi nSt s mi co emt o cl i mh n n i
p -
ss r
C                            ao t h eR                               s s e   e r t    N                           it id sd r                              ivn ee ds a t u c r is                                 a o                                  .
t s t
nre                              gd oc cn                               ne isv
n i mr e n
_                                                                r   i nlo
t fi c
          's r
r nlsS eo noha n oina e v e
etn ga                               e c esr                                .
r e ci e
o                                                    nr                             il t
ea l
c                                                   ora                            dy low a                                                                                      nl   r ae F                                         t e         nt                               np n                                         e        t a o orp o                                       l p         nh et                             it it                                                                                      c a
e e ea wl e behnt c ci r yargot m wnc t
u m
f vi t
o         mse                              es l
s i
a                                      C           e gss pg sn E
el l a
v                                       t n         ae nn                             i nid e         ak                             Cf n i m
ooe c
s          mae                            R     d s       Cw                               Nn e       Rg .                               t      a s                                            n e s        Nnn o                               at A           r ivi oat n ice f
i vt niugndf pnpo eit ePcp.
ip l
r,s eosdine o
C         inh te                              n gm R           est                             io N         Saa                               Sc V
l ea r
I l                                         l'                             1.             ll   l .llll   ll[
p
,sd r
u ad e
epsn nr sh oi monEne vher a sve n cdse oeen o
mit dl t Fitf e c n it h n e pi adn on seia d lnPol nc l
,e s i p
sow e mewia sh nem CCsrem i
l i
o at h n e
R r 'e b o aHmesoam t
geWol ut u v oe c
or sdt u c it idc i do Nf sm v ef.s,edcr ar eo oi. der e n nu e aaedn pf h
Enh p l
i pf t
eFocm haenb r
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it t
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neu etard  ef s6           uasos   nie         yt tst nCa esy e it                                               t ns                                  qd oah            f   ar nf ois i
i ear s e oe s ne e
g       ense l
ef s6 uasos t
die feit lo t it nnp eio  a c e         n echli        ata      aiain t l vi     ea s mss t
u etard e qd oah it nie yt st it t
ce se    Enf       t c epm                n o i f d     d o nhlo i t h        s aodLi laevo rd             e    orioia      t leT f
f ar nf nCa esy e ei lo nnp a ns eio t
n n eyaAx       .       uid nd            t et w ot neSr t pio n                   eoe                         n f a deiie l
ois i
s r
l t
it nar                 o  ebi                  esrdi t           s   s ai         a n pt       c f t t    an      nne napt ed    e n           r r an                     ooncll e         oiE t c e .
g ense di f s
eMie p      dcrliSeata r         rtddt p    efs it i
e chli at aiain ea ms c
i or s t  oa lt r r f ic u m         a nF ic eP       Odnv      e ac nutn    r d ein nu fodei ts ee pt e r s oosrse e d uoe m                                                                        r o       dics        de 3pteh aon                  an C          if n ie 'ee          r           w    ,iri t            n   e e vl ua y t
n e t
a     yminTeP           nn ed e             c nianiklp eds c          r ri a . nn d     ioo      bem cmu             ac      f    isp r u nnn age      PotgoMtnteo t
l vi s
c s uiv     ne      niet eah t es L                   t a nnt o                         h r mic si r el     Atene exn        mel i eoi    eop n  r t
t c a
inmd          t e
o d o nhl Enf epm laevo e orioia t
od eh    Sash 7 Cah insef t
n i f d i t o
snC    ivtat h c m           a o new mu a a,up    ao t         t fr                                    t edt                                  cl          ei pnain    9t 9o eesbr        ee op    eiloeht r vit a f         yl ccs             r     h            oel ae Ded        1 pnnasu r            oe            ,h eh pe a pvt Or us    e   epa u       a shata      ccWdt
c s e e t
                                                        ,n         e   s  r  t iuf osym u E d s Aee uSmmu  r r od s t
aodLi rd h
ne nat    .s e    l a es e etr lr e eiroeac gr                                  t cr   Jte nforf roior  vie     isht           ci f
s et w n
euwpa he rd od  hl aeer efer        t ed a edt n h     aorh     oe N             Tpa         TPPpppa                 Dasdi               Tcppt O
uid nd l
TI A
leT n eyaAx.
T    e S   s n
t f
R    o p
f a n
E    s W R e                                                                                       6 O               o           o                       o                   o P             N           N                       N                   N N
eoe o n deiie esrdi r
O T
ot neSr ebi o
N            l l
an nne ed f t s
f o
it nar t pi c
I L               a r                                     .
t t
k C               e v
s s ai a n pt ooncll or oa lt napt e n
e                     d n                    c h                                             la o         t e
r e.
r t
r an a
c        i n                      t                     a g                   y le f
i t
d e                       n                  b e
e oiE eMie eat rt ef it s
r t
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v                  d s         le o
dcrliS p
r                 t e
t c r
r        f                         p                   a t
i ddt s r r r
o          e r                       m                 t r
d ein ee oo s m
a           s i                      s ic                                     n                   n a                       a                   o d          d s         n                                 d                     m r       I             e                       e                   e o         e          v                      t                  d t
ic eP Od e nut nv ac n f
c         c           o r                        a                   s a          n           p                     ic                     a F           a n  s      m         im.s                    d i
s s e u e nu ei pt e od e ua y dics d aon e w
n                 d e
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o   n     r o .         sg                       s                   v i
r sr o
t a  o   f e           an                      a                   o lu i
t n i 'e e
t a      ec r        hi ea t                  h                     r p s.
r
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t a       ca n         o eTe crh              r e ap e e    s t
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n      df of e d er o e celesni  en  gm      ee            inuniemS e b el            t eee ih    t e      ve        nwr      rb sn          l t
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r        s eab    t      n inpor            r ey t          n osof    evcmmli oic            b se bo h is    c                                                ri              n gfin ee d .t                      r e y p pb                      e npnc          si                  es s    nn                                n                    r e            g      at          vu t
Go aih s t
n    ae      niht e          olyb ad laly nit                                  ecmiah                      a      aa em i
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t snmf esianfr      t          f          ot.uses sc          ueg a        t ae em    t no                  mari        e              sr              u    i it    h aiocgd                                        s ea n l
mi.c nd n1 yeu er nie et s t
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m.roo      n  o er ri on t    v o ge  e xt pvlg i
ont rt a
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ar g nsna t
r  o  r pa          c                                2a    l ul ooeol                aa fer ooitc ee  sc rd  gave t
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-        t e                        vl i onwr o              mgn cmd nia                              n d          ae      ca    ei                          i xior ieissg                          ri om em su ic sys f
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e        btc eriescr e                  o r  ll ef r aat it in en t
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.                  n                                              y
aRs ni l
-                  e                                              r
ns v one ePe e 'g. at a n1 r e r
_                  v                                              r a
eis r o t
e r
v a
p c
w
-                                                                  o t
,h r
o                                            t s
me ey am a(k r
is
r -
_                  s                                              e                                  m
insh d oym omsliano it o1 t r gn a
_                  e r
t i e
c r                                  a r
d3f et t cvmt l
u                                              u .                                g s                                              os                                  o a                                              sm e
n e m r pb u e h
r e                                              r a
e o e sposC gh ir is r r eoes u y o w c e yf oodi s
_                                                                                                      p m                                                    r g                            n t
t r rl e s afaprf t
t no                                  o
h s r
_    s              n                                            ier                                it c
nd v
r              e                                            icp                                  a o            i ic                                              f  n t
t a spr o
c          f f
r n
uo                                  e
n cmro sd u
_    a          f u                                              st i
s l
i v
nut n gn iOa s
_  F              s                                                    c                          t c
al aosraa nie pid d n i
-                                                                da                                    e
.il r
-    n            e                                              e e                                r io                                                            t                                          .
r ed a
d .                                              av                                  rd o e t
ealeu h n ng dJ e
a              us                                              ci                                  ct t
: nr et e e,
u          lcm                                            loc    e                          t n
c umm
_  la            ine  l lar                                  ae E
: cAs, f
v            sb no                                              so r
en n d
hm t
e nn n
iopr                                              ac                                dle t
r lysa wein oo nQe Tawie n
cf heg t
n ao ogaad oo a
iep f
or e o gl f
ao                                              n    n                              si  m e   e                                           e mra it y al i
r r rt
v c  n                                          eg
.d ee t
                                                                          -                            st  n t
niio pe mne l
ce err gn                              ise r
mei t
ao                              Ciic r u                                            nl o ce                                            at                                Rf u f
eoieb x
Cr                                              Mou                                Ns
t t r
 
evloo r
_          et mro      becaidSo      welpn a n i n t
gm inoen ediwnpe) net r
e gi                mar  se p8,so              mAe h ei                            .)d eao9anut er npm gmd d inrf                                                                            lyC st      i
r r o n ghi e e
-          sd n ps pw s9coyoinuivl r
eeruSib misnn net m
ee                ba Ru aih es e t
t f
r y k ou t
lc t gv edlo r o scl a
t Go
eef na h nl sxiCr o
-          wfs Ta      u     e2 a1 S e h 0 ,1 Ca 1
b oo er o o
a eqar s                         oNf n( o dnd t
aI u smocc PsC t
mpe mi.c a                  nd oo ayaa t
db oeh Tef eef ( t R
n1 yeu     lona er y
E es V
o nie mr                 dee r eemtod.
n S
r t                                           et s s
S o
gs eh o e           nMlpr ar     urg vodid v                                      vsu i aro nsna of t
ont                a                                                              r  f t e rt c n  r                   g n eub e                         oc ah i
pO n a pcgh e e e
nl int          r be h ehr T beFI    et  n df cenC n e ed ioA                             mdd m      i r                                                                 inn oexe o                  w ha8      LFnd   oer ac         s tv e .
m  ihf r c i t
etaV                    sau a
o                                                  orivd                              h)b t
_          cTd       e d         9Ae                        nirH                              Ca nwn t
C    a                 t 9 C c       p a ns  t i e a a pd n t
ni l aRs w ,heis tr -r o me rv                eyone e 'g. at           n1                   e           r v           a a                                                   am              ePe r
insh       d e                                                                      a(k t i cvmt eoes            s t o1 d3f et t t r u y o wafaprf oym omsliano  r r c e yf oodi       n      gn is it e a  m e o e sposC gh ir l
-          r r   rl uee s pb            h r t
v         h s o                  s a     spr                                                 t ndn cmro i
sdr pid s   d n u
al aosraa r l          nut n           .il nie r
gn              n iOa ealeu                                                         e ,
hed n ng         a dJ e f    : nrenetn ec dumm                              cAs, e
Tawie        nn     n n r lysa e              n f ogaad   wein oo oo                         nQe a
            .d or  r ee o glniio ao            pe     mne       r r                    rt eoieb t
x         t t evloo l            mei r gm t
ediwnpe)             net inoen ghi    e          e r
net r r                 o   n m lc eef na t gv       edlo scl h nlo sxiCr   eeruSib                misnn o a b oo t           f r
ero o
_        db oeh             Tef eef ( t-aI u smocc                              PsC t
R E e s
n                     S                                                               S o
I R
I R
p                    E                                                               E L s                     Y                                                               Y A e                                                                                                     3 T R S
E E
Y R
p L
C d
s Y
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e 3
T R
SYRC de tu n
t e
t e
n                                                                    t u
it e
e                                                                  it s
s n
e                                                                    n b                                                                     i en s
b i
a                                                              t e h                                                                 ae e                                                               ub c                                                    m       lae n                                                    le         v v a                                                   b         ea
s e n a
  -                            m                                                    r o     d h s
t e h
ae ub e
m lae cn le v v a
b ea m
o d h s
r r
r r
o                                                   P         ns o                     f                                                                 an t
ns r
c r
o P
e                                                   d          r o n
an o
p                                                              oit a                                                                             a       t c F                       t t       ina n
f d
o n
r o t
a                                                     n e       o mv  e lp                                                                   it it a                                                                              m      t ac u
r c
l u                                                      s f                                                       s     h e     r la                       s                                                     e t t r so s
e n
v                                                                             s s n E                       e c                                                           e t c n f
oit a
_                              c .                                                 A d  i     eo ud                                                   f v   m s se                                                   lee
p a
                                ,t d ra S n d o es le n     e et s n n                                                   ei t vu me ai v iao                                                     ol r o rt gc t
ina t c F
sm ue                                                    ose      oe rf f Sd                                                   ImR      Pe I.
t t
n n
o e n
a e
mv o
lp m
it it t
a l
s a c f
s h e u
u r
la s
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v s
s n so E
e s
t c e
n c
A d e o f
c.
f i
ud v
m se lee le e s
es
,t S
a n
d r d o n
et s ei me t
n v
n vu ai iao ol rt o
gc t
r sm os oe e
rf ue ImR Pe f
Sd I.
I
I


rt a cce gc                                              nCe 6y e e         w em ot  gh     s   e s   e oi e
rt a cc e
_        o   einf sc     eeli.ctr ms            dnihl  d                            t ssmv r
nC 6 e e s oi e y w m gh s
porrr mf    e unwf v         o em          art eigt    eecem      d et      s s eu r
e gc e
v nCe         naeee ot e ecr rnt po t
.ct ms d d s
f ole rb      df eddmr o  inae ad ai a ago n nrf           a a us h t s a sm o uhct n eImrp            vl                       p t
e e
it                                                      i s                      npi r cghd d                                      ooeximd pstero mr u           e e r aiet r e o rewm.f                                                               o uye i                            r rh vnu       it      o et ers usartongysasl o                     peol m re en pi i o es                   a rh        rt t
e o einf eeli r ot sc o em nihl eecem ssmv t
s  v ev apanieio c n       t               i t
mf r
n vf lo t        iz gT o
r r r
_      n e
e unwf v art eig d e s
it co      cr ict osi of nisr i r i
eu s
t st a
por nCe naeee ole o
h eral  a e sinoC          n al e e.h      s e      t eociepa               r t
f t
h wref d nyet.ou            y        gb r a ce n v caf - f - ic m r v
v inae ad ai a
m r
us t
oion t ri          igeal      l      f      sl o ws i r
a rb df n nrf h
v e eh n           ou au      ns
s ecr nt po eddmr a ago a sm t
_      o cce sPsr pns sn              e ei t      e as i dt        ih vtdc a       Aa l
t ot e ruh n vl i s p
s smd u
npi r t
C   ef wAet               e         ye isaee         n                     Qvmt            u hit r indis i
i mr ooeximd u e o uye hd d o ct eI it p
nf                  r h   f             r nt an i
cg e o r
aob T eieCu  v sse avlrd  aed b    n ei                         yan r         sg       e        f    s f-     tyf f 0t eye t
rh o
h t err et r
ewm.f pster mr e r
            .d e n r 'e t nvst                   e                               es i fea0nvimu s                                                            l f apo at e eian              n p                    ch e eens              at s 0,r reEa esm                 oye p eee            e
it aiet r vnu o et s sa r
_        ugaso onh      nt      f esf n e et       mbid      f n st 8       u
rt sl o peol a rh r iz gT o t
                                                                      .d gs l
m e n pi i o es er u ongysa s
aiey e     ch s r
v e t
oaer c 98 en t
e n vf lo c n r
r o                                                                            nt ne grd cseema          ee gsye .               npve9 a aey nt d t ri                                        l ad eiv n sa l e cr sn arvst                                                            mncs t
t t
o        oh1    pMfae oe s al wen i
v apanieio i
eyo Bh                                  ie:           t                      r     al n r
t i r h
me Tpwesmab     r                   sem t ah sdingn yl.sh                t f
al e noC n e
od ge      nh svw.wn s
.h n
e aeieo l
it cr ict osi st er a si e
s    sr t sot ao ona            r icTmn f
co t
in dlb 7 r t
s t
di
al of nisr i a
                                                            . e a e n dtaim e
r ou y
as n
e eociepa ca h wref d nyet.
et i e r
gb ce t
evvr poop eie ss      iai v t vt i       f-l    inmep         e o o9teetr xt                    eppm   r r sa ahRde e r eassabd        ceel         ee  d     or9 nceof gp1 esnpo h
e m
mmo I
r v
Tiic R   e
n
_ E  s V   n                                            S I
- ic o ws i e eh n ou ns r a m
R  o                                                                                S p                                           E                                   E s                                           Y                                   Y e A R 4
oion r
T S
v
Y R
- f r
C o
f sl v
et r
igeal l f
                                                            .                          d e iv c e                            o      n n                             r a n                             pm t
o cc sPsr e ei e as i ih vt a l
ea                                  sr o iam r
au t ri i
pf ur ply                                oe oe                                 r p pm r                                  gf t o pi t h
Qvmt Aa t
aa                                  gt     s on                                is     n e e s
dt smd dc e
r t    i                               r o                                           dd                                   v      mt     .
pns sn u
t c                                            iee i t f                                    o se    sn c
C ef wAet e ye s
F a                                            t ne                                 ye m e se t
u eieCu aed rd isaee indis n
err                                        s n                                           d o                                 f aag i
nf i
o                                            i c g                                  s f-     a t
aob r
a                                              ndn                                            n nsle a d
f h
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11
 
miowri sn o sb igt ngat e or y t r a aen j
git 9 n r
r aa od e n
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n e es Me eoe smpan x p pa o
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n            aiwsmn t
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eo I,
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pl n a.
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r1 sao 9 o d pl F
_                o      eict o euyemtga                  s            a     nst                    t nesry C    r                                         n etn etnlct psNbpmn n          s oeo                    a belatye sy o            t   et ae mtnwv m e pemibs t
pe nst imye o
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la t
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f c
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e9 l
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x e
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t et e n Sv o n e 1
a  pio a  n a sca r) t eCenPsu.                      lyu          ee sr e sgyriiovm                r o epnl m trf ib      Rpte e sos      srt          la        aaer      ah c      c  seo r oim p    n geGeics o eo                        t ule n ph t pteh l
h sf ge s h h ch c e n o etaoh e g9, n gt et t
n      Cwhin eimNn          dnr    sf    f        i vas if r
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spog i y2 t
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s                                    om r
r ulp Se e ohlt a gedt o ua h iac t
e    fu e.                          t e nl b v      e    c                        e r     n                            o O        aa                            mr ep d        smr                            gd n
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Amyne Os wteieih nnp dMy lt s
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m iLmcf bo h invi a
n      mvo                            aa r r F                                      a      er gp                            oe pp a
i n
a n                                      r am                            r o o o                                  O        ni                            ct n it a                                    t       a~g u                                     e n      mn i ea ivlp l
pe o
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v                                    m e      n ai e                        t cn ei E                                      a     lpc  h                          f t e n f
,t cf i adc o n s af i
a    d a                                  e n
t i e o eb dC o
a      no                            sm
-_                                                  M ed e
t at ede a
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eloo vn sn ve at ri t                           e vit o  om p
s nil nu e or  r m                            ed os i c LI m    Cc o  o                         ic n e Lar 1.
_                                                  11
 
n aa ngat r
od    e p      or y          a t aen                  j                git  9 n o
amd              uc1 ito r
r ns          r pl s c et smpan        x        p panipvl n ee esr                Me        eoesr p0, u heer r ns iyee
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t t ot x                    p            eb sh ns3 lo
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i el    t  c  se staE              h    e          f      r rdi ys nCarr      e r  c oh nt r nr                                                              pd t  t sdSa    e c su ueo  n f    mh u
t    ep epn .d    an e
s          d e  e    d e arRue
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of    o  st t ezt ia ue c h          i      l e
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o eo sr eaia sh gr ht rl s )t p
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ot e d
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es        oor ear                ab P e sin edh emtsip v t t
t nngui 9
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l yu o ca Ciaesw aaemi9 Ql b dl d e t
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etnoolcmm                        RmTea                    a itn o me                                  Ne cr e t i        s  r                t e      ct                          s            a  r                      .
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ot 8 nn e e nd eN alpa e
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L  s                          Y                                        Y A  e                                                                                                  6 T R S
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e v                                      ni d t
sl e                                 law p    -
f ol  l a                                     C dt                                      heR na                                      t    N a d                                      s r d no oo ee it d
is a s
t c sr                                      n r  e eed ir                                        oc d n                                        cn i r
gu                                        e gan t
s r                            ns o                            oi                                        nr t
c r t ora s ha t
F a
st                                  e  low nt n                            ec                                t e  t      a o                            diih                                lo    nh vt                                        et it a                            o rk e                                m    mse u                                                                  o la pr o .                          C      e gss E
v                            m a      wno                        t n    ae nn e yi    t                          e    ak t
a t
t fez                                      mae m
n ai n                              s
-                                  es a mr g e
gleo  ar A
s e
s s
Cw Rg .
Nn ion r vi ace nuh                                C      oat n ant                                R    inh e est      t Mai n                              N    Saa V
I
 
r  e        nr d ae                                                  gTf a otel pugs nasui r
o eAfog r                                                                                    n . r r  n            i r
I, pl e ee0 f
t n t
lo8u pe r1 6dnst              isao r                                                                  r n a d.pleo                F                              t                             9 o imye c         e9 f etche no            S ed mst                  x su          aesrs s          h          l e ha sf lofge                              la 1
hgt het                    Sv oc ne n                                              t e o      etaoh e t                    ,l o          c                                      g9, n u ,rr e n                I Ts          el  i s r spog r r t n        i h oniacorulpa              Se e ohlr r
t a ngedt o r      t ir y2 ua lt            s Osgsuwteieih              n       nnp                  dMy r t
n  Amyne                      (
e stny ae                  dne o og l
e      .reeeh                                                                um v      t sned e nsn eb                cd e                      n          e m    s siot t t u n nii                                            r t                                      t                            e qi odi            no        el          s   sefno
_                                                                        i odt pe a
.          m o  iLmcf e af a bo    ,t i
hcfinvi      t i        adc          oo neb                  dC C   t                      n    eri acmel                i    e                       t s nf abn gt    s de                                      ethtrl                        o ys eo l
r t oil            etnt pe sh gr eb ht          scs u)tc i
p sr eaia epbna                    int nytoTue ed u                                          sl tg
_              Rladi          otsde            d ind    s              .bd  ,nt h e o t  e         a nn        .
nngui                  mnn ae9 su            t 9              yuc os          wei  ca t
Ciaesw Rg            r s
                                        -  aaemi9 edl ic h m1Ql t
Se b dl l
nc        d e r iord e yi C                              gme Uwdeom
-                  i                      t r
r e r
_              Noebt R  s        n        oteou                              ek c      e rd e e
p nn he he nd eN j
alpa      jo           ot 8        r r                       ag h cla 1- a o nst nf i eemd i
t t
t t
cd               lmmml              t sn1 e w ie          on        Pn L
cd sn1 e L
is  s a ol           aei                                           w ool ee    e ev es                c at          d e 9 syt             cp         Ao         a se h n o             ae    r           r r       agr eh ele eoe.                Sdd e       eear r                                                ivp                         r
s nf i ie w
_                mmt         l l
ol aei 9 syt cp Ao a v s a c at d e ele eoe Sdd ee h n o a r
pr c    vr vtsgt eee epue ort cs n dn a at t t
r r agr se r e e eear eh ivp d
d      euat e o yi it sb t
t r
sii mn     SwSr uoLf aI am                                         hh o Tsb R
at t mmt l
e E    s V   n                             S                                                       S
pr vr vtsgt d
_      I R    o p                             E                                                       E Y
eua t
L    s e                                                                                      Y A                                                                                              -
rt s a
7
c eee epue o n
_      T   R S
e o yi l
Y R
mn SwSr uoLf aI am Tsb c
n hh o t
it sb sii R
E e
s V
n R
o S
S I
p E
E L
s Y
Y e
T R
7 A
SY R
C d
C d
e r o a
e o e o r
s s o
r a o h
t h
s s s,
t e or s,
t t
r ie e                                                     inro
ie e inr r
-                                        it d                                                         t ivnu                                                    de a c
o t
_                                          t                                                       t i
it d d a ivn e c u
_                                          c r                                                      cd .
t i t
ao                                                    lenw f    I e
c cd.
_                                          gd                                                      e    ev i in e r
a o lenw r
s ce sv nl                                                       a anR so s
gd e
r e
I e
c   e                                                 dermec
f i
_        t o                             li r d y von of   a c                                                                                         r r p em a                               nl r F                                 ae                                                         Pr
ev n
-          n                               np                                                    im          o o                               o orp                                                s   sge
r i e ce sv s nR nl a a o
                                                                                                            ,f sr
e s d me s
_        it a
c e er c r
o li r
von t
d y of a c
rem nl r
a r
F ae p
Pr im
,f o np n
o o s
it c
it c
n o   a   nP es                                                 i t   hi  t t
i hi sr o
_        lu                               pg                                                   a   e     an a                               sn                                                   r c r a v                               ni id                                                 d     nPlP E
it p
Cf n i     aL i
n sge r
s  mAe n  rSt h R d                                                   o   o Nn C
o a nP a
e nm f    t a                                                 r t
es t
n e                                               l a         eor at                                                   n lpcf  e fice ip l
t t lu pg a
i o la    r s t    r t lt n
e an a
igm i
sn r
d    esu vos o                                           d Sc                                                 A   Omre V.
r c
l       l'
a ni e
nPlP v
id d
E n
aL Cf i
mAe i
sn h
R d o
o rSt Nn C
t f
nm a
r tn l
e eo e
a r
fice o
lpcf at n
la e l
r s ip i
r t lt t
n i
igm d
esu o
d vos Sc A
Omre V.
l l'


i)ll                   !
i)ll lllll1l n
lllll1l
it l
                                                    -                    it n                      u                  l a
u o o c
  .                                        f o   on                      c             l
l a
                                                          ,a t           r       r a n                       e e     rd                       r                          ic        oio    ri lyrs h     en t,htehr a        d ef gs de bo ns                         Saoet    pt aa r            t e nv drt   ue lo      t misoiec h a uta a c                       eICebhMp e  t ai icd n eff vo esv ncl a           i oianr           e ur                h t atnoiw.o                         f d swl n
f t
el     r n a iue o o n qh nwseecs e
r r a n e
h c ehh nds .                  h it tod  e mn e sw          inn ga e oo                          em             rleiaf                  issu i
n
r    TT iHiee                                            n ol v e     weibit              cs e
,a ic oio s
vro bf t
r e
a r   .tn  r s
rd ef gs Saoet lyr ri h
rp sd N      .
e n d
8gerb     .e              pumonn ud r rh e3e     am           ae         9nbpo                   t r   ptepc es                      ae pymeo c.           t iid9issmp hf e1 r
d bo ns pt a t e t eh a lo misoie Ce a r nv e
aiese r       e                    hm s Oor e ra da            nnv t
,ht e
aai              t t s     d ut          r         lsu ingv s                                  sn        r        ot p                 an eeoirn           e   h   'e   w t
r t
n    e   roe ne             d  r         cs                eosin ct avad t
eI bhMp ai c
ny e                        m i pd e n eo napmur t t e epedo s r                           n cawrel            pan          eb m
drt ue h a ut a c n eff v ncl a
eCmoo oaa  f         c r e af i
icd t
ini        isep        p y d                   md ae nelaich          ee m  mf i s l
a vo i
l int t                             ri o e   odhgl sn      fo ne   sn eeol                   t l
oianr e u h noiw.o inn f d h c r
leict r
t at el es sw nwseecs.
ab opo o        dr v C  vs nu-a      ai      needbve                 i g         t wtaat h g         i              ne us ogooRn         t    ecbi                              n                                   f r
h od mn r n swl iue e
pinfh              t l  i yn sd hi                     de mh   t    ess                   eo b
ehh nds it e
nyde       aef c t t                      of uni mta sl Pet wAPm al ics t
ga a
aehtio                  er t
i t e n o r
at r u odat    ema         n      c n    s ir e i o ebs c r                     e     e aes ur                          aa e     e vo                                  v o f
rleiaf TT em weibit iss o
r                o ic                    rkl p nmi.h a o   vs            nml g      aae  smt             t        pe on ulio e                         mw rh srr eat if     et,p   r    i ss ,d hin t    s  adcn        socfaawh                          oc fi h          r nm           eat         t oi haf  o edd t         r h
n qh e oo n v iHiee bf cs u
icngdr a ei t
e e o
nuhnnid                                                                epw eet a                                r r       f      .
.e ol pumonn vr t
ial               es     n                 aing              h aa os h r     oamd          cs eioieei     mml                  n t
r r N
n o nToon              e         rd we e b ov nei en      r nt eccv osii f
a
y  ai t lppeii bbo g t t        it   n  t oev a
.t p
snPioa aigL c rt t         t gr r r                       hi t e   r    uudl i e l      r ro e nAnps r
sd 8gerb ud r
sicoodcein o   s s   f f einnit h e                     h eclu        ccna    r e
n s r rh ptepc e ae e3e am ae 9nbpo t
p p aESfumu     i s    Mddeecwid                             Tefxiraiioh cccc                     Oim R e E s V n                     S                                     S I
s h m r
R  o                                                                                              S p                      E                                     E                                 E L s                     Y                                     Y                                 Y A e                                                                                                                 8 T R S
pymeo.
Y R
t iid9issmp hf r
C f                                  f o                                 o k                                 k d
aiese e r
n                                    c                                 c e                                   la                                 l a
e1 r
r t                                       a                                 a g                                     y                                 y i
r c nnv sn s
n                                  b                                 b v                                  d                                 d o
d ut r lsu s
r                                   t e                                t e
Oo e aai t
p                                     a                                 a r                                 r i
t t a
m                                    t s
s r
t s
ot p a n n
n                                     n                                 n a                                    o                                 o s                      d                                      m                                 m r
ingv da eeoirn e h 'e w eosin t
o                       e                                     e                                 e t                                    d                                 d t
t e
c                        a                                     s                                 s a                     ic                                      a                                  a F                       d d
e oe ne r
n                                                                      d .
m i pd e n eo ct avad ny d
n                     i e                                 es o                       s                                     v                                 vr it a                       a                                    o r
cs c
oo r r lu h
r i
y p s.                               pre a
n awrel n eb m
v r
napmur e epedo s r isep p y t t pa a
o                                   imm  e imro E                        t                                     sl                                 st
m eCmoo l
_                            ih s                                     ab ho r a ar hepe t                                     ep n                                     cl                                 co e                                     na                                 nt m                                     an                                 an e
o sn nel ich leict c e af ini md f
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r        goedit eh    ap onPg  sr e                     r      d ud o r. al h nd s                                                 ich               is      sa fo r         p                       t t
iva a
a     uniacany r cei t s r  asu e .d sesis c d an l
sr e e e d ud o
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goedit e
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r is a o r. al h nd s eh p nPg ich o r
sn er btsm e nnoad t
nie r
o o veAeS    n nRTd                   ea                       yno                 eue lbi     cpu sd      n oo                                          t i
p s
t t                 r     .s              l b ioi    t a         vd s any nd a .u            r   9   t. oi rf t
a uniacany asu e
dtaz a c    eh   t nc e9 o w9    i    peiotn cas r                   er ici   r     hairicS i u                                              f se              of i a t
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t f
ninmi      e s n1 ec            e 'd ci r.i
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                                                  !  y e ed vn      t i
n e ne eyR r
di  l eee  ri inom.
r cei s ieC sesis i
r e       t gna esis               3ne      na        r,t h ou                                 a eT   nh m is ot gO r yn t
ob er ecein yO h mct l
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h cn       a aRoraa                                         e      ml m                                    edi        re                          f n o  gecviaS    n fd up            h ope                iw m          yad la l
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pob t
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n nRTd e ea sd o yno eue o o eAeS i
h h         ga e oae n
lbi t
lt sise n cJ e ei obl,t             n a sn o i gh e     sag z
.s cpu n o b ioi vd s l
Aor n ns ur er               v     r t n os          lc o inn nt        mis dunf  eac eid r
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t d aet e ocw ic rde s o
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et n
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n a nfieh ge            en .                      inei echa esni 1 i
t t
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ce messie s   c                                   it     so        igil     c e puyrd an                      t bdseih ar t nicn hed          o len        t t
r rbl c ei c iso v
ip    s ei v sd e aeJRh    dxuOe             uieh av d              d o   d i cres    q u        oh c         t ineh   r t                    t  Seiwmag                         Fl iif e           NTa   .
l r eh sa di onua oot a
R   e E   s V   n                                 S                               S                 S I
otcar t r yf adl pmt ut t f
R   o p                                  E                               E                 E L   s                                 Y                               Y                 Y A   e                                                                                                          9 T   R S
t r
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n                                                  a          .
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o, v s a9 so n
o                                    s                                               dt         e c                                   m                                               ina a                                 le                                                    r     ir F
.d f n a
b                                                     o po n                                   o                                                 icrp o                                   r p                            l.                 f p
a sn ieh en i efae inei d
it a                                                                     a                 ic a u                                    e                               n                 e c                               o                 pn la                                   n                             it                   se v                                   e r
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a r                t e E                                     e                               e                 nb a
ech e i 1 s c a nf ge.
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it t
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ye m
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c tce d an bd nicn ed len ip igil e ie seih ar s o t
n m t
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d                                  a e
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r                             i m                  n o      r P                               S                   Kp
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                          !ll                               l'                           l         '
d o i cr q oh c ineh aeJRh Seiwmag Fl i e NTa d
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sl                wyv eresu ul is          ni            - blb             or cdi ee o gl bsrt hot    epn e           t i r foh ur i e   c     ett va m   t ed     or pl po ep s,tn cr         a     ded ef                 Tper a eprdeth mr ns mn                    a o                          t a pt ca      winen p esm        e e geai            cad                         p og      u ql e gt am i
y y
lpg aad st .o usp r f       r asn st                                epn                                    r nrha                                                dmdi sovege i
er u
oiug      dn t
- blb or ee o gl e
enedestnf      se                    aon n mi      d             it ioc        v swanya c no   c 'nt r
ul t
ocein r
ni slbsrt wyv s is e c et i m ed or pl cdi p epn t
n sv eo        emhi no    lycaie ct t          l t
hot s
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v t i r po e
a ss              sbfish od intem e                 eseae ir e vi t    l s       d                                      t ca t
,t e
n  vi wdseid    e     e gpca ern eem r
ded oh ur a a eprd h t
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  . e er noEns          b                                i ewncronpoi n sl eym mhgr at                       n m
et mr a pt m
m e k%bi ivd in r        e nx sb vie a c          i efe od f
ef a
cn ec itr    e gP a i n dnkdaopm c uge s e0us                                                     e Odf a i
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o        0 t e      h n .aseg a                       r                                     hu      t C
a wi p e m e ns cad o
r n e1 Pc i
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ef h as ntnt o f                                rEeeMa a         vd           al sear   e ar t
s n
ed hid e  seei L n sd r
o ql e
evt ge iaf    f h a o ear sayer                      sh   eo rdi sieged s.o nw.d e up r t h csme                     et pet r t r nt h c           a eis   et ric n a gO ep       rf poct i       f nr                                     uomf          i t
geai asn st
ixamisoa      n cl mc du dede          aah  t na erdd          a       d~eyelne e
.o u epn c nen am nrha lpg aad st r
i t               r e   o s   r u ot c an                mhf            enenra o              cdl t dl i p s e pd h clag o cs         pi comiat i
r f
r       r et r es pin           oh it y gt yra mca e h t
i r
sp dmdi sovege oiu g
dn enedestnf t
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se mi s a c no ocein eo n aon n io taal r o
r r
o lycaie ct eprp w nya c
'nt n sv emhi l ss sbfish em t
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in n
it sl eym mh at r n gpc eem mf n
gr n m
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d uge r
f vie m
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nt e o up ed L n r i sayer f
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did t
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e lauin N e yi f
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t nisf l
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e          pi R n i ev awi n f
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wnh                              n eino                  lauin N e yi s a ea c   s o    lasb amb l
f R pliSc Vmaomah ma Oewl aipalih e RE es V
r a              a  os    R r    n eg mlr ci o      vih          elaee t s e r ie t
n S
sp wmeht e r s ,c l
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yet gnmet      gn mr    ebieo      ia isgvuf t
E L
s                  ea    l io vf n's r e laa un oh n u ea udme  o n    r nhcori        u ocesr ner s            t ee c r r
s Y
ego        i a cfct a ca t
Y A
cs eS          eeih pt eevo              r R pliSc r
e 0
Vmaomah ma                               ptxhtaipalih Oewl                   mare c af          f R    e E    s V   n                   S I
1 T
o                                                          S R    p                    E                                     E s                   Y                                     Y L    e                                                                                                           0 A  R                                                                                                            1 T
R SYRC l
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n                                    d e                                      a m                                   d s                      e                                     e r
e a
r                      g                                     e o                      a                                   d t
m d
c                     n a                     a                                   is n
e e
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r        s            e t
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    .                           u rdese
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m coeio i t ct m
                                                                                                              . ne e nef  s snhew it lar  mrerpnci  iot          e ebf eae                    f    t h s 3
np l
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baiat mu . od nr q            niu  ir      sve ana n aE Eh eo sP Sta ghnt sn eterdc r    .ocag                                                                      e asr              ps        m r                                          ee      e sneseminI      t a          Rt
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                                                                                                                                            .d d r e pf nuegsgu oryue r t
sa h
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n addoind n eal                    Nnesaoegvmes                                          icbee            se      t t s epr c rk miee c                              osnnr                                    el icn e r eapcu us l
E ll Ill l
e er ogc pah ebo f r            eiu hcac t
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R o p                                        E                                                    E L s e                                       Y                                                    Y                                  1 A R                                                                                                                                  1 T
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n                                          e                                                  d o                                          v                                                    e it                                        it a                                          c                                                    m u                                          e                                                   r o
la                                        f f                                                    f r
v                                         e                                                    e E                                           n                                                    p a                                                    n s                                                  e h
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-                                                      U                                                    P


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eeiwAoie isr m2 s c cst 4
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sl ee en ah etrh lyo e cvm n n t s n t
( ic
v en a c e nie e ere n e nr v r
                                                                              )
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    - E          uosl soa                      e    eo      mri                                      on db sinine                                                t aditnio NH OT eaer roais c            e t
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TM                                                                                    r ad I
AO              pradamdepec r
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1.
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n l
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n eh a                  d e o                r n      hl Wrexk at t
s.
aprdnpo                              c            r ero
d a w matuao. j aofuiHe icrrdn.
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h e s eoh de et s o emar eteis n
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r t o cde ma a mb ad t
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ot c
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t po ost lyeeg o
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h e emie r
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s sn el o. Df it sl a
t n
o b vri iaptet ras l
emeim      f              shsUf        f a L 'e    e      a3            eistt a
e e
e                                m ae ,mh r
r f
S                  rd      e                            .s        nt m
r n p u n8 e enhi oaot xl r
t nr uo g                  le    rheet s      en          au .                r let moe I
epu l
-      L efode man                b ot           eue                            sub s T  m                                ocd          h iqc                  b c       ed    oe o      m    ectna                r peeTnl                i r
o rh n n t
o rane r
e of o9 cpu an o
u er  cpur N          e A
C      gs uo r      am              hi r
                                                            .h      e    inoi          d ot d
_      L        a s plpr gt a nope egt    et ch              ef e r
er cpecne
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E          ga  s ssu e s
dia a etuae l
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ed d s e e
gi s e            nd lao f
iems
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_      O          eel        t              n ei, c 9 'e      s s      Dh u t
r    ov    s R          efib cs                    el                      o                    eneb heio
_                                                    l 1                      t pegse        e                          ps s u i
.      P          mtnr    oua ept d r            d imh t
wtn      oi      r ,s E
t odt      nis e         ic,            nnu at r i eb .
t      t f
oec d a    l,me e NH                                                                                            vh ninif                    f x ,2 pci                  s                l a    nekt n i
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t                rl o us son i
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ovg            eb    wh TM                                                                                    vo oi I
t s                      r
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_  RS ET    e s
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-  PP    s                                                                            N RF    e                          s    s                              s
                                                                                        /
s
_  AO    R                            e    e                              e              e E                                Y    Y
_  L L                                                                  Y              Y CA
-  UV NO                                      e
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n           la
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d                              i o              r e
EO                                      e                            t
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s                              n             e
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R                                  d                                g              u O
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e              e r
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a                              h                                a A  F                                  s                              m n
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.r p
o                             .
e n
le                            it              e r
ei9 nl l
it V  a                        la    b o                            d                a E  u                          n    r                             e             s la                          o     p                              v o              e it            .
,esmt r5 r f
r v                          a     gn                            r p              u E                            r e     no i i                                          d p    gt                          im              e o    a fac                          s             c o
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e             e la      e 's                          s              s u   dC                              n              n e             e im    i R l
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l                               c            ic AN i
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S                                    L              L ll
t t
 
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n h a noit aaa niaf elya e cnh t
t                        L            e i ar e
ri r
c        s                        f a
t r
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a            G          inms t
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h               f eot id               f       o    ydf r e     n d
i ecpnr eaw h r f a AUegenper e
m      f at s        ai a                 de em t
t a e eir e S
e       r' g .
I m
t s ne      to se ncsg s  .
a et h n e
b u        o ss r      he    m      -ye nn aslien i
s ee ep pi ob m
r       pe    t er t
et d xml L
n        s n        ,i        a cesu dit o        sve      s u                  n ad i                          l c              isq          eeike yi  t lyer        hh          a sh e
pgm n
n Tmic la c      a         t r
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s s  e        nfe af e    ne ah i
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                                                                        .ee s T
t o upe oat ief lad nc st r
i lia n e
e nf n dl uooc o v co e
t NA
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t at ue r e e, wono n
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T          e sd    Et t
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A5nse  9 tie c R
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P1 9uhn IS  m    .      ue    Pem                    oTla L        s        a cra t I r     l T    m o
h n, cr in o al n st t u r
n o      t s t
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a           o         m.
o et w o j U s, oird hd al E
i A      ic    . r     t            usuPs L.
ei Dna i spt t
P      i s f          sm      sb7        nyd gd eit dm      'e    e                eisiann nu9              l M        oa      e d      os9      bcys E
a t
L mrc      ss na isE1 ivPr e        sf aauk wt      r B
aa ee geh et a
ds        eh      eI b        aeh        n  o O
e unoiat y t t urt u c
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lid        reo      hht aew t n lat    ht c   ef pmn he a t
d 3 gmr ed r
R        s                 r           eo dsy si P        n o o f
bc o uh lumna m mu h cca OT np it aa r ed e
t         edO ve n s
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nnoteeil E            e l,d   e NH it cm            v  edi su 0        eic ct          sa sd u
t r e uo ec pa d
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r e lc2 n-    ee o      rk e TM I                            t T o "p ss f o8        h p no    Oim      Ac8                        ri u AO        it TR SF RS
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              . ET             e s
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s AO R
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icna sn fo l
h n eh a d e o r n hl exk
l r n e el s epio s vaeh    ovcCes  sefed    '
,a e.
eee  wa mPe            a oid np s aa) w dsmE
aprdnpo min Wr t
_                                      t d  r  enl              r                  vi vs r r ic e                                                        isee
c r er at t rh c
_                  ot      l                                    f f              r t a ea nnamid r u(ie                              a o       nRh n4 v                    e        T ao n io in s o a 5. e          r dC t
o n
d sh            cl c                                              h n neTip                        si ocM0                ie
nisag on st in vaio ea nl ed e.ce w
-                  aR            g
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                              .ee lat      c e aa a ct t     c C
a a
5 oii h f n t
oec ht epedi nny t n t
eo ri pct m
ges r e gi n
Ce st f ir                                                          marag t
b e r
s                                                            s ntei T
o t a a nb e cwae n
t Rvmraasteaervpe                o  S  n   R  'd s nd Eai w n                                                                          o c eo
ui d
.                                                        i i
mase it r
_      S  e       Nsets) 1                          l sN                d a mpe                    dt ivr l
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I L  m        ye    nbo n          mi)t c7 la ed l
t s
e r               p b h r e:                                                            e c
d er a er qee u e
-                                            e aaa r Cewa .ss Sr n nre on t
t cg qoa v u3i t
T  m      d epvr              en rd                        od  e          t N  o                      ealar      nL pco ;a ro s r
e a
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v sm ma eb vl ac ea eit t oie r nr s
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os s d o oCe e ni r
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cp aa
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                            . t T     n                                     v                                                                r eht er e                    i t
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n P
                      . A.
et od a hd s
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e nr e e
                                                                                                          .pns            u dpe        r ntatcnd.                                                            nie l
M b
P                          i vhmd s c sl ea i
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L a abs ar n
M                               e r n y et s (n s     t rf
B h h we h o f
                                                                                    ,se naa          igne        al gctaor r euos                  f p      i  meRs s      i eesne i    .
O tnse em nio NR e
L                               gn      s                                          gh            r rk            e    s u onh se                                pTr o p e o r t
e vt s a o
B                                 gu                      mlcii h         r                                              a    ain
OP mies e
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lp cr AH o cnn.
t nhiie t    rdc          a    erstn e eoh r
m lip r eoa a TT ek ppit t S M mxcse o
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E L P         s CF          e                                                 s                                                                                 0 UO         R                                                   e                         o                                  o                  1
R N sn A A o
-                  NL                                                         Y.                          N                                  N YA TV NO UM OE                                                                                     l.
L E P s
m CR                                                             n la                                    a ER                                                           i t
p LCF e
o                          r e                                  r g
1 s
LO                                                             a z
s 1
v o                                  or AL F                                                                                                                           p e
UO R
i SS                                                              n a                        t a                                is AR                                                             g u                                  s LO                                                             r o                          q                                    y T                                                      t                            e                                la
e e
                      .C                                                          n                        d                                    n A                                                        e                          a                                  a
NL Y
                      . F                                                        m                        d                                    e N      s                                                 e                          e r
Y Y A T V NO UM OE CR ER LO L F ASS AR LO TCAF N
s u
s r
r                                                  g                          e O   .o                                                   a                        d a
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c                                                 n                        i s
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a                                                 a                          n t
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                      .A      F                                                 m                          o                                  o U     n                                                 s                          c                                  r L                                                                                                                        e A     o it t
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A o
c E     u                                                 v                          s                                  e la                                                  o                          e r
e V
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                            .v                                                  r p                          u                                  e E                                                                            d                                    n im                            e                                   a s                           c                                  s a                           o r                                  a h                             p                                h e                          e                                  e e
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s                          e                                  e s                                  s n                          n                                  n e
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c                          e                                  e c                                  c iL                          iL                                  iL                            _
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n n( e e a mensemam la a s
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it ea                vf er t t c en s
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o e c r
Er        s f adt c ot f
s se eef er it h sr c ef t
u sme l
e y.
dl nSt                  a   o es a                          uiep c ei iaoPn o rem,la                w si nli a                  r dfi lar n o            u t
s gd nh r
wovmnp                              se                            e snqe oiso neCt ev asReci                en voh Sa      k ice ie t                 ri u    d oc                              cf vi nciud s t
d vdi ae e t
lpaN                    oCt of elio d prr e s                                                      r t
r r edi r pt einnat ool r
edeia    de de r        nc eet                p5bowd                eg n        r                                    r ol ah t inn a e oc im9f          t a h   o l
r ovuwtoprh r r alpe r oyo oe d u c
e        el t                v ariTl f i          it c  t                     9 o n                 k m       ivut          n              not              e1 m
c ph cia aeat le c t
s s nI n e e .AR              a     et n mfo        c        pcei t
f ina dd e eu smsnd e c mcdt in e e s
                                                                                      .c s a T
a ct u
S     o       e r k nS j
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'e i e i n hf caird ob n r
C        t h x    c ae  oiF      i t
t t
cdsd          ae      mtf tag e nu s ann ane L                            t r       i           it h H
nf oeau e esh uaTf n gn r
eis hl      azv        r                     o ossd nct nw                      rf a ,miv eonwl  o a a und f            l e
e r
i C                          w ins a                                             r T            d eige s    e an        o ew5 ect c                      pi                nf c d gyu et h n9 h ef l
,e ioo t u nq sat o a o i it r e nnim t s d s ee o nh r s
t A              e     uvr        t l
.yr n
e caaeit s te W
est d et w e er t
t cse ox                  vf la9t  1  se f                             d usr s e              iop s           ,a         eiocef e sf                        r E                                      nh s4l e              nd) t ed          a i                                            i dl nahissn r      s eci2l h et                          o n r
s upc o a e s
H                          oa                              ic mAcwd                  llya r     heeTe  ah rwe          eoL T              otnTcd c e                                                                 ei n(r e kn t e na Ce        o  n l
c i n s ves amiad icio ayovse nmmv t
ps . b si n r                                               t M            G    m e. ec    ae t
ui t
l,t O
n d g c
R
a e
                &annu                    mensemam  e   ,r   lar a  r e snh a s          t Edliid        l ccn        cdd lce vo ae ori                    er t F            Sn        eeo                          ret  e   vatecet          i r  ebu S     e s       Pf uddc                AadNad                OwLliwh                t s T     n N     o A     p L     s 2 P     e F   R
l t
& O 1
l hl r a o e o
L M A             s                       s                     s                            1 E V             e                       e                      e L O             Y                     Y                      Y A M S E R
,t aa a pd A h e
t R                                                            n O                                                             e v
er i
F                                     n                      e S            d o                     r p
mt a
R              e s
amhn eh r r f
it c                      o O              s                      a                    t T             e                       e                      s C             s s                      v                      e r
t g
it A     s r        a                      c                      u s
ht sf n m e yf p
F                                     e o       y                      r                     a N   t c       lh                      r o                      e O             g I
m r
a d      u                      c                      m T   F     e  o                     d                      t n t      r                      e                      n A         c  o                      n                     e U   i o   e r  h                      i f                     ic L   t a
d r r
r o
m egeh m d ed at aidt oo ss a
t e                   i f
i l
A     u C e
f ie m
r                    dd. e f
t t
u V   l a        a                    ly p                    s E      d     s                      r o                e v    n  a                       al                  d .
T m
eev E     a   e                                             us d      r a                    lc e                   lcm T=    e                     dd n n ne l u      c                      a e                  isb no i
n i
            -i  n d
r mi d oh h seovat r e S
e   a                      ee vb                  i t
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m                    iss                      cf e  r o                      na                    ao s
lt h ep ee e n wimmst pQePab a t
u f
r ud erlep.
r e                    h eh                    e v c e
I t
C a  p                      ema r                    ic e t
r L
n k                        pr                    er  r t
r u
a e
edi emaeae m.ar no e l
mg                    r u r
s n wnh wms rl r
o                          o or                  o  c R    W                      Cp                    Cr e I.
cus
.s C
rs s aWs i ie vega i
H ei nmpv s
nc et oSt nps s o
oiue e vssomh or e ge n r er T
as ee. o eie sd peonoi t
e si it r
a c
r r asl hRo A
h e uwekb ic a set, c gi au ot f
W iwn sr a bv d t r t
h ah c
od gc ef hTis.nh ec a t
t c l
ySo t
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f a vn w.e E
i eat a
ad. gmiog f
if io e v s
u H
ed rh o gh g s n yin earsos c eci t
t n
T ic a t
n n
at slb n eyedivn a udidi l
t t
n s
n O
en ic o ee nd C
nu t
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o e olaet emr M
n a rd e an Rmacyrpm c
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Nrfaib nur of r r a
ie f
c ennet p
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id inmteics e
nd, t gi nl mp ef g
pi f r r n F
eu ig ognla at h
t e uxnl u
mc h csapm ounei ri S
e db Sneepo T p s a pi at s
T n
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e ar l
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r aims vos l
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r s.
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r n
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pon                                          r t c                            o H
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p U
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O      gse . gml f at n cela 2t i nipa            tr is             e nit n ece            f y
t at gn e
                                                                      &i t it t v
A n
o R                                    os                    mrr                        r F
ta nd r n nu sn z
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o st em a
-  R                                                            .
er o n a
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u V
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gp ci e
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s h
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h                                               ae            oe                o r
v ag n
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oi E
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t t
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g r h le a n
n                                   t n      o    e         er              f a                                                          d o E
mn pt ee e
v lp e       mv  i        i c g
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m            t l
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u                                    s s
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t ac h e n d  n          d n
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f s                                     e     t r r     iea bl                  a s
v sk e
e                                     s ne s
m n e elon mr ive e
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ai t
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s v ri e
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_          c                                             n              r
mi c
_          c .                                A d  i  eo  f ae l n
o t
a ud                                  f v      m s            st                r se                                  lee      es            en                u
i m o
              ,t                              S n                      ue                s d ra                                  d o le n    e sm                s et s                                  ei t    me          ies                a n n                                  vu      ai v          y g              y iao
h vr u h l.
_        t sm ue ol r o ose r t gc oe r  f t a f en aa it la u
-        Sd                                    ImR      Pe f
Sm                Q
_                                              II
 
np                    uoie t or de itwne          ar      l xh oa hw eT l
l it k u r                  r pnl smek l
i          vdr m loas e
v w yf y            r s.
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o   mse                          es C      e gss pg sn t
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s mae                        R      d s  Cw                          Nn e  Rg                          t      a s              .                  n e s  Nnri io at A      r vi oat n ice f
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O a nt                                rf r oae atcn mcr t e Piscn                                                              et t lvenue hs9                  a9  nu kecnl      oac                  un na e osdr n             af m!l enraonio1  asi t,,n g1            oaf a ei it nt t
t h ane s ,
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                                                                              . t oi n cg e            sisreeUn essegP cnmeug            u o    wd mbdl est      ean  r      eis m            s ne e sl    ueb        e ca onf v
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pr ei p  p Gg n    s a mtn L                      rd                                                  is H
l epet a s d e fr h p g netoot in t
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adnluda sht .n s        lee boqu C
T            Saet  'e n      c pb eegf    d n d  eh acwmws t
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o n  isd nt t i orien h      sbe    n s ol e r    l e ehutcscme          v ea it e H            fo et ei mreep t
r        c  s aimh d      t a
rb T                                              t n              e          e Cth uh d enPeL                      a a te e                        pt o n              ,t  d h M            RrhoTeh                          icmhi      tvse      se    s  or O            Ntog . t                t eA              cgsd                e ea R              e ius  n oi aebt icc S f r inf  o  e cr ene gr nr a u c i        e  n o i l
h p F            h or nd nin s                  e ieioh            s etr S  e s          Tmh UiSht a h t                    S pS c c i p as c
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L M A              s                                  s                              s      6 E V              e                                  e                              e L O            Y                                Y                              Y A
S M E
R                                                                              f R                                                                                o O                      r                                                        k eo                              d.
-    F                                                  n                              c h                                                                  a S              t s,                          e r
l R            inro                              t                                a O                    t                            g                              y T            de a                                n                            b C              t    ic                        iv                              d A  s          c dn w.e e                                  o r                            t e
F  r        l p                              a e ce  ev f      I o                    i m
r N t c
r                              i t
s O  a          snR                                n                              n I
T F            a    a                            a                              o A  n        dme er        c                    d                                m e
U  o          von                              t e                            d L
i t            of    ra                          a                              s p em r
A  a                                            ic                              a V  u                Pr
                              ,fo                    d
_      l a        im                                  n                            d E  v    s            sr                      i e
n    sge                                s                              v E      o    a      nP                          a                              o r
t i
hi    t t                        h                                p s.
a    e      an                        y r
e    c r a                              r                            imm sl e d      nPlP                            t o
i s    aL                                s                              ab mAe i
_              n              h                      h                              h or o    rSt o                                t                                ep C                                          n e nm f t                                                                cl l
r eor                        e                              na a    lpcf                                m                              an n            e                          e                              mio o   la      r s                        c                              r t ti i
rt lt esu r
o                              oa f r d
vos                            f                                r e ep d                                          n A     Omer E                              Po V
 
seeg            ,is      imorr      d ar          otueob soucr t
_                  r  sl l
ee        e  g d.
e  o r e eieondnd rh c r                n  hf t
ao r r e
glys s nf u
t o asiae t
o  et xedr          vc a u ost          er        ep p                       r g r r s spmn                                          tu o  u oae v
_              n  osn                        ze isb          ow r e          oiFHi n  area nmele t
am                            v ns e
e  rddi      t oi l b a e      v  hpnu        t on          ee.e vr s  b    edi pa    dlul        or e                aA          ipsh e t
n        o            ohi  pr      m e      lu            s nf ou sx e  t    t e    e      ors v              p                    .
s ae v            oeWe              eh                      e imm f
m    a  ot ntat            c ss    ot        s oo        t r xei shd m_
h e er ngale      .n        t d                      ebt nce T          s  ck ean                      sn        er                            utn S    o        n                          ea      hl          .
d mes                  e at apptime t
n l
t    oyt I
C                        sr r        u ,    .              te u m L         e  c  nOeefoa                ned      t    t a ne ri  l e n y, m              e nnc u  e i                                    pit H          m i o f          l    t    r y    t h  od        lpeil                lp C          e v inh .a igc vsoph  ec nee            oe    c t cf  i mrg uib    qam T          o  s aise isn            t    cr  ed dl eau ev      o a /e ia      l i
A                                          nh re r                            t
_              p d engnar,                              t ot o        cla n      o vG
. W          m  nh a  t    eracemv e          edae ml b ncapr      ly t      eia&it s ue h lgah        w                            nvd elonrsES i
E          e  r dnr e I
F    ei m H          c                              ea gr o    Sh            c      soap t
T          n be    apnrd o
                        ,mienH                a ut    Sto o          e r recp r a                              nd a e se t                                  t M          m  md      o awa uecio ns .                      cu  Ct d e        Goaoe l          s, O
R r
o  nc u nr  d ped se mon ri R yl Nlit    la    &t segu i
r        l F
f r  e deodeonpt                epn t          et      Et        t      nd e    e h e                      o  t o  nd      s  Siaio  n          g Trb cal n a if S    s p                            Soc        Afi in        Pumam T    n N    o A    p L    s 2 P     e F   R
  & O
      ~
1 L
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Forwards for Public Release,Info Re NRC SMM Held on 980714-15.Summary of January 1998 NRC SMM & Watch List Removal Evaluation Factors Also Encl
ML20237E313
Person / Time
Site: Millstone, Dresden, Salem, Crystal River, Clinton, Cook, Quad Cities, Zion, LaSalle  
Issue date: 08/26/1998
From: Tracy G
NRC OFFICE OF THE EXECUTIVE DIRECTOR FOR OPERATIONS (EDO)
To: Kilgore L
NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
NUDOCS 9808310137
Download: ML20237E313 (82)


Text

---_.--_ ---_______ _ _ _ _.__ __ _ ___ _ _ _ _ _

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UNITED STATES g

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WASHINGTON, D.C. 20066-0001 o%...../

August 26, 1998 MEMORANDUM TO:

Linda Kilgore Public Document Room LL-6 7

FROM:

Glenn M. Tracy, Chief

I/M Regional Operations and rogram Management Section, OEDO

SUBJECT:

SUMMARY

OF THE NRC SENIOR MANAGEMENT MEETING JULY 14-15,1998 Attached for public release is information regarding the NRC Senior Management Meeting held July 14-15,1998. Attachment 1 is a summary of the January 1998 NRC Senior Management Meeting. The Watch List Removal Evaluation factors are provided in Attachment 2.

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i NRC Senior Management Meeting Summary July 14 and 15,1998 Region ill l

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Following the June 1985 loss of feedwater event at Davis-Besse, one resulting NRC action was

- that senior NRC managers periodically meet to discuss the plants of greatest concem to the

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agency and to plan a coordinated course of action. The NRC senior managers held their twenty-fifth such meeting in Region lli on July 14-15,1998. The previous meeting was held in Region 11 in January 1998. This most recent meeting was structured to review the status of the Watch List plants identified at the last meeting and to review the performance of other plants to determine if any changes should be made to the list of facilities which require close monitoring l

by NRC.

In preparation for the meeting, NRR and NMSS, in conjunction with the four regional offices, AEOD, OE,01, and RES, prepared background documents on the plants and materials licensees to be discussed. Inputs for each operating reactor plant included a summary of the most recent SALP and SALP history, a discussion of current operating experience and licensee performance, current NRC and licensee activities, performance indicator data, risk insights, and enforcement, allegation, and investigation information. Data pertaining to safety significant hardware issues at the plants were also provided. Inputs for materials licensees included a summary of recent performance and activities, including significant areas needing improvement and potential chal!enges to future performance. To enhance the application of information

- summaries, pro / con charts and Watch List removal matrices were developed. This information was distributed to meeting attendees prior to the meeting. It provided the basis for review and f

discussion of each plant's or facility's performance and for senior management identification of -

those plants and facilities warranting increased NRC attention.

In reviewing the reactor plants that have experienced significant performance problems, the NRC managers have set the following categories of performance based upon plant actions to date to correct the problems and to achieve improved operations.

Cateoorv 1. Plants removed from the list of problem facilities. Plants in this category have taken effective action to correct identified problems and to implement programs for improved performance. No further NRC special attention is necessary beyond the regional office's current level of monitoring to ensure improvement continues.

Cateaorv 2. Plants authorized to operate that the NRC will monitor closely. Plants in this category have been identified as having weaknesses that warrant increased NRC attention from both headquarters and the regional office. A plant will remain in this category until the licensee demonstrates a period of improved performance.

Cateaorv 3. Shutdown plants requiring NRC authorization to operate and which the NRC will monitor closely. Plants in this category have been identified as having significant weaknesses

. that warrant maintaining the plant in a shutdown condition until the licensee can demonstrate to the NRC that adequate programs have been established and implemented to ensure substantial improvement. The Commission must approve restart of a plant in Category 3 status.

In addition, plants may be issued a trending letter that formally communicates NRC I

management's concems regarding adverse performance trends. This action is taken to inform licensee management that plant performance, if not corrected, may result in the plant being placed on the Watch List at a future SMM. Finally, senior managers also consider whether plants that have demonstrated superior safety performance will be formally recognized.

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NRC senior management will transition to an annual SMM schedule as directed in the SRM l

associated with SECY 98-045, though the ongoing review of the NRC's performance assessment process may result in a revised process in the near future. Recomrnendations will be made during those meetings to add or delete licensees from the list of facilities requiring increased agency-wide attention based on demonstrated performance. This program -

represents an effort by the NRC senior management to focus agency-wide resources on those plants and issues that need to be addressed, to communicate the concems cf senior NRC managers to licensees with poor performance or adverse performance trends, and to ensure that coordinated courses of action are developed and implemented for licensees of concern before problems reveal themselves as significant events.

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3 Summarv of Decisions L

The following enarts list conclusions reached by the senior managers at this meeting and from the previous meeting for nuclear power plants and for materials licensees:

NUCLEAR POWER PLANTS -

Meeting Dates

. Cateoorv 3 Cateoorv 22 Categorv 1 Trendino Letter JULY 14-15,1998 Millstone Millstone 3 Crystal River 3 Quad Cities 1&2*

1&2' Clinton Salem 1&2 D.C. Cook j

LaSalle 1&2 Dresden 2&3 JAN 6-7,1998 Millstone Clinton Quad Cities 1&2 l

1,2,& 3 Crystal River 3 i

Dresden 2&38 LaSalle 1&2 Salem 1&2 Zion 1&2 (1) In July 1998, the senior managers did not review considerations for decreasing or maintaining L

the level of agency attention at Millstone Units 1&2, given their Category 3 standing. On July 21, 1998, Northeast Nuclear. Energy Company. submitted a letter stating their decision to cease operations at Millstone Unit 1. In an SRM dated July 22,1998, the Commission directed the staff to no longer list Millstone Unit 1 as a Category 3 facility, (2) in January 1998, Commonwealth Edison decided to cease operation of Zion 1&2. The l-licensee is no longer authorized to operate the facility. As a result, in July 1998, the senior managers concluded that Zion 1&2 should no longer be listed as a Category 2 facility.

l (3) In January 1998, the senior managers concluded that Dresden 2&3 met all the Watch List removal matrix items except for corporate management oversight and involvement in plant operations.

L' (4) In July 1998, the senior managers could not conclude that the adverse performance trend had been arrested at Quad Cities due to the limited operational data since the last SMM.

MATERIAL LICENSEES Meeting Dates Facilities for Priority Attention r-

' JULY 14-15,1998 None JAN 6-7,1998 None l

e-4 Qincussion of Commonwealth Edison System-Wide Performance COMMONWEALTH EDISON The senior managers discussed the system-wide performance of Commonwealth Edison l ~'

(Comed) as well as the individual performance at three of its nuclear facilities, specifically l

LaSalle, Dresden, and Quad Cities.

- The senior managers recalled discussions from the January 1997, June 1997, and January 1998 SMMs during which they recognized that while the SMM process is oriented towards assessing individual plant performance, they were unable to separate the issues associated with Comed system-wide performance. This conclusion was the basis for the 10 CFR 50.54(f) letter sent to Comed in January 1997. NRC senior managers again considered these corporate-level i

issues, in particular the cyclical performance that has marked the performance of many of the Comed facilities.

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The senior managers focused on the limited measurable progress from Comed's improvement initiatives. Since the last SMM 1) LaSalle remained shut down,2) while Dresden safely demonstrated dual-unit operations, it experienced several reactor scrams, and 3) Quad Cities just recently restarted following an extended outage. While it is too early for outcome performance indicators to show that operational performance is improving as a result of the Strategic Reform Initiatives, the senior managers expressed greater confidence in both the f'

NRC's and licensee's processes for monitoring and engaging indications of cyclical performance at Comed's nuclear facilities.

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SPECIFIC DISCUSSION OF PROBLEM FACILITIES i

Cateaorv 1: Plants That Have Been Removed From The List Of Problem Facilities CRYSTAL RIVER Backaround Information:

l Declining performance at Crystal River 3 (CR3) was first discussed during the June 1996 Senior Management Meeting (SMM). Concerns at CR3 involved Florida Power Corporation's (FPC) handling of several design issues, their non-conservative interpretation of certain NRC u

regulations, and weaknesses in operator performance, corrective actions, and management

. oversight. At the January 1997 SMM, CR3 was placed on the Watch List as a Category 2 plant, due to the continuing decline in overall safety performance. These performance lesues included weaknesses in the licensee's design change processes. A Confirmatory Action Letter (CAL) was issued on March 4,1997, requiring NRC concurrence for the restart of CR3 prior to entering Mode 2. At the June 1997 SMM, the senior NRC management acknowledged that the plant was in an extended shutdown and in the process of determining its extent-of-condition. At that l

point it was too early to evaluate the effect of the performance improvement plans ar.d l

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considerations for maintaining increased agency attention outweighed those for decreasing agency attention. Therefore, CR3 continued to be designated as a Category 2 plant.

During the January 1998 SMM, NRC management noted overall performance at CR3 had improved and FPC had made substantive progress toward their planned restart. The programmatic areas of design control,10 CFR 50.59 evaluations, and corrective actions had been inspected and found adequate. NRC senior managers noted in reviewing the removal matrix that given the plant's shutdown condition it had yet to achieve a period of sustained operational performance. Concems were also raised regarding the reconstitution of the plant design basis due to its vintage and design. For these reasons CR3 continued to be designated as a Category 2 plant.

l The NRC Restart Panel developed five major areas of concern to capture broad performance t

problems which included: management oversight, engineering effectiveness, knowledge of design basis; compliance with regulations, and operator performance. These areas were thoroughly addressed by licensee management and performance in these areas as well as l

overall performance has continued to improve. Inspections in these areas prior to restart noted l

improved performance in all five areas.- CR3 was released from the CAL on January 30,1998, i

and achieved full power on February 10,1998.

CR3 senior management turned over during the outage and subsequently replaced a number of upper and middle managers with personnel from outside the company. The new management l.

has taken the initiative to correct longstanding problems and improve programs. Performance l

has also improved in the area of licensing.

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Operational performance since plant startup has been good and operators have taken more of a leadership role than in the past. Licensee management provided strong oversight of operations following plant startup and has stressed conservative operations over competing schedule pressures. Material condition continued to improve with a small backlog of corrective maintenance items. Timely correction of operator workarounds and reduction of control board l

deficiencies continues to receive emphasis. Management established a low threshold for identifying problems and self-assessments have been effective in identifying areas for-l

' improvement.'

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Areas'where the licensee is pursuing additional improvement include processes for plant i

modifications, procedure changes and clearance tagging. These areas are being addressed by i

licensee management, as are the reduction of the engineering backlog and performance problems attributable to poor communications among operations, engineering and maintenance organizations.

SMM Discussion:

The senior managers considered the Watch List removal matrix in determining the appropriate agency response to the identified performance concems. In reviewing the Watch List removal matrix, the senior managers noted that Crystal River 3 met all the criteria for removal from the watch list and had demonstrated sustained performance improvement. The senior managers noted that Florida Power Corporation had substantially improved plant material condition, 3

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management oversight and effectiveness, engineering, and operator training. NRC performance indicators confirmed continued improving trends.

The senior managers concluded that Crystal River 3 had taken effective action to correct their

- identified problems and to implement programs for improved performance. As a result, no j

further agency-level attention is necessary beyond that provided by the regional office to ensure improvement continues. Crystal River 3 was classified as a Category 1 facility.

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SALEM Backaround Discussion:

Salem Units 1 and 2 were first discussed at the January 1990 Senior Management Meeting

- (SMM) and have been subsequently discussed at every SMM since June 1994. Both units were shutdown in May and June,1995, respectively to correct longstanding equipment deficiencies, l

poor material condition, weak management oversight, and ineffective corrective actions. As a result of the January 1997 SMM, the Salem units were designated as a Category 2 watch list l

facility. On August 6,1997, the NRC concluded that the licensee improved performance L

sufficiently to warrant modification of the 1995 Confirmatory Action Letter (CAL) to allow restart l

of Unit 2. Senior licensee management provided effective oversight of the Unit 2 restart effort and successfully fostered a conservative and deliberate operating ethic among the operations l

staff. Since the most recent SMM, the plant operated well with the exception of an emergency l

diesel generator (EDG) turbocharger failure which resulted in a forced outage on Unit 2 of about -

a month. Also since the most recent SMM, performance improved sufficiently on Unit 1 to warrant modification of the CAL to allow restart of that unit. The Unit 1 heatup and restart activities were conducted in a conservative manner. Operator performance during the controlled shutdown of Unit 2 for the forced outage and during the startup of Unit 1 was excellent.

The licensee has assembled a strong management team who set high standards and exhibited a good safety ethic. Management and independent oversight of the station were effective in i

enhancing station performance. Strong management attention resulted in significant improvements in the areas of operator workarounds, control room deficiencies, and the operations procedure revision backlog. Management was also effective in establishing a low threshold of reporting problems throughout the plant. Overall, management fostered thorough, independent, and self-critical oversight of station activities, as well as effective self-assessments in the major plant departments.

The maintenance organization exhibited strong management and teamwork, but continued to be l

challenged by some weaknesses in the planning and scheduling process, emergent work L

activities, and the workload associated with efforts to reduce the maintenance backlog. The I

corrective maintenance backlog was large; however, it was properly managed and a reasonable I

plan was developed to reduce it. The preventative maintenance backlog was also large; I

however, safety-related preventative maintenance was performed as required and management actions were effective in reducing the backlog. The maintenance self-assessment and corrective action program continued to effectively identify and evaluate problems. For example, the j

licensee's self-assessment of their maintenance rule program was thorough and addressed j

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. many weaknesses of the station-wide program. Overall, rnaterial condition of both units improved significantly and was considered to be good, l

The engineering organization continued to provide leadership in important plant activities.

l System Engineering was effective in their support of plant operations and was actively involved in the resolution of emergent plant events. For example, the root cause investigation associated with the EDG turbocharger failure was excellent. Improvements were aLo noted in the in the performance of Design Engineering. Although the backlog of engineering activities remains large, the licensee has properly prioritized it. Numerous equipment modifications were l

effectively implemented to improve plant performance. Finally, the licensee was effective in l

improving a broad spectrum of engineering programs. For example, notable improvements were made to the fuse control program and the vendor manual program.

SMM Discussion-i The senior managers considered the Watch List removal matrix in determining the appropriate agency response to the identified performance concerns. The senior managers noted that

)

l Salem met all the criteria (or removal from the Watch List, including the demonstration of j

l sustained, successful plant performance. The senior managers noted the successful startup l

and operation of Unit 1 and continued good operational performance of Unit 2. Also,-the senior 1

l managers noted that the licensee substantially improved plant material condition, safety culture, and management oversight and effectiveness. The Salem management team set high standards for performance at the site, provided the resources necessary to improve operational performance, and instituted a robust self-assessment process.

While the maintenance backlog remained high, licensee management demonstrated a strong

)

understanding of the Wvidual and cumulative effects of the backlog and is effectively managing the prioritization are klution sf backlog items. The senior managers also discussed engineering performance at Salem and concluded that, while it is contending with large backlogs that resulted from discovery efforts during the outage, the engineering organization is providing -

good support to the station.

The senior managers concluded that Salem had taken effective action to correct their identified problems and to implement programs for improved performance. As a result, no further agency l

level attention is necessary beyond that provided by the regional office to ensure improvement continues. The senior managers determined that the Watch List removal matrix and SMM L

presentation supported this decision. Salem was designated as a Category 1 facility.

t-i DRESDEN r

Backaround Information:

l Dresden was first placed on the NRC Watch List in June 1987, removed in December 1988, and again placed on the Watch List in January 1992. Significant contributors to the decision to place Dresden on the Watch List a second time included weaknesses in: procedure quality and adherence, communications, execution of management expectations, plant material condition,

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supervision and control of work activities, work performance, and engineering and licensing support. During the June 1996 SMM, senior managers concluded that an independent special team should be formed to evaluate the performance of Dresden station. This evaluation was conducted in the Fall 1996 and the results were presented to the senior managers at the January 1997 SMM. This team concluded that safety performance had significantly improved in plant operations while the level of improvement in engineering had not yet resulted in fully effective problem identification and resolution. The team also concluded that the results of improvement initiatives in radiological protection, maintenance, and self-assessment were mixed and identified significant weaknesses in engineering, design control, and surveillance testing.

During the June 1997 SMM, improvement in the Unit 3 operational performance and material condition was noted, but senior agency managers remained concerned about continued operational challenges on Unit 2 created by equipment deficiencies, the engineering difficulties that remained to be addressed, lingering questions about work control, continued weaknesses in procedural adherence and continued maintenance issues. NRC senior managers recognized sustained improved performance at Dresden during the January 1998 SMM; however, concerns

)

regarding 1) the continued evidence of cyclic performance by Comed plants and 2) the adequacy of corporate oversight and involvement in plant operations and problem resolution i

resulted in Dresden's continued designation as a Category 2 facility.

Recent performance in operations has been good. Operational evolutions are usually conducted in a controlled manner with excellent communications. Operators continued to be l

challenged by scrams and transients caused by material condition deficiencies. There were 6 l

reactor scrams (5 automatic and 1 manual) over a 6 month period, three attributed to engineering performance and three to maintenance activities. Operators responded appropriately to reactor scrams and performed well during associated startuos. The Unit 2 refueling outage in March and April was completed in a Dresden record time of 41 days.

Plant material condition, though greatly improved in recent years due to management focus, still continues to impact plant operations. Improvements were noted in the work control process, but maintenance errors, mainly attributed to inadequate procedures and work instructions, continued to cause equipment problems. Despite these material condition issues, plant equipment responded as designed during scrams, minimizing the challenge to operators.

Based on the effectiveness of engineering staff in identifying and resolving technical issues the NRC closed CAL No, Rill-96-016. Some weaknesses are still present in engineering. Although engineering's support of operations has been adequate, resolution of severallongstanding problems has been ineffective.

4 Performance in Plant Support has been good. Licensee self assessment has been aggressive and is a developing strength for the last several assessment periods. Self-assessment has continued to identify weaknesses with routine procedural adherence and maintenance activities.

SMM Discussion:

The senior managers considered the Watch List removal matrix in determining the appropriate agency response. Because of the high number of scrams since the last SMM, the region

9 concluded that sustained plant performance was not demonstrated. However, plant performance has improved substantially based on improved conduct of operations and plant material condition. Operators have performed well during the scrams and subsequent startups.

The senior managers focused on the six scrams that occurred since December 1997 and

' debated potential insights that could be drawn conceming the overall performance of the site.

The senior managers noted that safe dual-unit operations had been achieved since the last SMH and that the scrams were generally the result of historical problems. It was noted that gerate performance during the scrams was good. While the number of scrams was high, plant equimnt responded as designed during the scrams, minimizing the challenge to operators. In l

addgion, due to the general lack of equipment problems during these transients, NRC senior -

L managers gained greater confidence in the reliability of mitigating equipment. The senior I

managers concluded that, contrary to the initial view of the Region, Dresden had sufficiently demonstrated sustained plant performance to meet the removal matrix criteria.

The senior managers discussed risk insights associated with Dresden as reflected b the IPE and IPEEE. These discussions focused on equipment reliability experienced during scrams, HPCI system reliability, and recent improvements made to the feedwater level control system The senior managers determined that the level of risk resulting from the reactor trips experienced by Dresden during the period was minimal.

The senior managers deliberated on Dresden's improved performance in conjunction with the agency's concems over Comed system-wide performance and the performance trends at the other individual Comed nuclear facilities, specifically Quad Cities. While system-wide performance remained an area of NRC focus, the senior managers concluded that Comed's corporate support and oversight of Dresden was adequate to support continued sustained performance. ; In addition, the senior managers concluded that the site had individually achieved a level of performance to support removal from the Watch List during the last twelve months.

Lastly, the senior managers expressed greater confidence in Comed's ability to monitor and

. address cyclical performance.

The senior managers concluded that Dresden had taken effective action to correct their identified problems and to implement programs for improved performance. As a result, no further NRC special attention is necessary beyond the regional office's current level of monitoring to ensure improvement continues, which includes the continued assessment of Comed corporate support for its nuclear facilities through the NRC's Comed Performance Oversight Panel process. Dresden was classified as a Category 1 facility.

Catenorv 2: Plants Authorized To Ooerate That The NRC Will Monitor Closelv l

MILLSTONE 3 Backaround Information:

Beginning in 1991, the Millstone units have been discussed at every senior management f-meeting. This is the fourteenth senior management meeting (SMM) that the Millstone Station l

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10 has been discussed. All three Millstone units, each of which ceased operating at some point during 1995-96, were placed on the Watch List as Category 2 facilities as a result of the January l

1996 SMM. Subsequent to the June 1996 SMM, the Commission identified Millstone as a Category 3 Watch List plant, which required that the units individually receive Commission l

approval to restart.

On August 14,1996, the NRC issued a Confirmatory Order directing NNECO to establish an Independent Corrective Actions Verification Program (ICAVP) to verify the adequacy of NNECO's efforts to establish adequate design basis and design controls. The licensee selected Sargent and Lundy as the contractor for Units 1 and 3, and Parsons Power Group as the contractor for Unit 2. The staff approved these selections.

On October 24,1996, the NRC issued an order directing that before the restart of any unit, NNECO must develop and submit to the NRC a comprehensive plan for reviewing and dispositioning safety issues raised by its employees, and ensuring that employees who raise safety concems can do so without fear of retaliation. Additionally the order required the l

licensee to hire an independent contractor to monitor the effectiveness of the new program.

i NNECO selected L!ttle Harbor Consultants, Inc. for this independent review of the employee concerns program.

The agency accumulated enforcement issues for the Millstone site since late 1995, combining regional issues with those from the special inspection conducted in 1996. Over 80 items were identified, ranging from engineering design issues to Office of Investigation findings from wrongdoing cases. A civil penalty of $2.1 million was issued for these findings on December 10, 1997. More recently, on March 9,1998, a civil penalty of $55,000 was issued in association with l

the licensee's failure to take adequate corrective..:tions with respect to the potential for air in certain portions of the recirculation spray system to be swept into the suction of the charging and safety injection pumps during the recirculation phase of a loss-of-coolant accident.

l Unit 2 recovery efforts have been delayed significantly due to NNECO management's decision to focus resources on Unit 3 recovery and restart activities. Unit i recovery efforts have been placed on hold pending completion of activities for the other two units. Thus, there has been no significant change in the status of Units 1 and 2 since the last SMM. [On July 21,1998, Northeast Nuclear Energy Company submitted a letter stating their decision to cease operations at Millstone Unit 1.]

In SECYs98-090 and 98-119, and in Commission meetings conducted May 1 and June 2,1998, the staff provided the Commission with its assessment of issues related to the Restart Assessment Plan (RAP) for Millstone Unit 3. In SECY 98-119, the staff concluded that the licensee had taken appropriate corrective actions to support the restart of Unit 3. This was based, in part, on the following assessments:

1.

NNECO had met the restart requirements of the October 24,1996 Order. The licensee's Employee Concems Program and Safety Conscious Work Environment were well-established and functioning effectively.

t-L

[_

A

d 11 2.

' Significant improvements have been made in oversight activities at Millstone. NNECO established an effective self-assessment process and oversight was adequate to support restart of Unit 3.

3. -

NNECO's Configuration Management Program was effective at identifying and satisfactorily resolving existing nonconformances with the design and licensing bases.

NNECO had also established programs, processes, and procedures for effective configuration management in the future. The Unit 3 ICAVP had been satisfactorily performed and the results of the ICAVP and the staff's oversight provided confidence that Unit 3 is in compliance with its design and licensing bases.

4.

Improvements were made to the licensee's corrective action program and this program was adequate to support restart of Unit 3. However, the effectiveness of the corrective action program can be more completely assessed by evaluating long-term performance, and thus, the staff will assess the program again in about 1 year.

l 5.

Significant progress had been made in enhancing overall station performance.

!~

improvements were noted in the conduct of operations, procedure quality and adherence, operator training, command and control, material condition, maintenance and surveillance, and engineering. Overall, Millstone staff and management were suitable and plant equipment, processes, and programs were in place to support restart and continued operation of Unit 3.

On June 15,1998, the Commission issued a staff requirements memorandum (SRM) providing its restart authorization for Millstone Unit 3. This decision resulted in changing the Watch List status of Unit 3 from Category 3 to Category 2. This restart authorization was subject to the satisfactory completion of all remaining issues requiring NRC verification. The SRM also designated the EDO as the senior manager responsible for verifying the appropriate aspects of Inspection Manual Chapter (MC) 0350 were completed and for approving commencement of actions to restart Unit 3. On June 29,1998, the licensee submitted a letter indicating its readiness to enter Mode 2. On the same day, the NRC's Millstone Restart Assessment Panel completed all of its activities associated with the execution of MC 0350 and completed its review of all of the key technical and programmatic issues captured in the Unit 3 RAP. The Panel also recommended that the EDO provide approval for NNECO to restart Unit 3. By letter dated June 29,1998, the EDO authorized NNECO to commence restart actions.

On June 30,1998, Unit 3 entered Mode 2. While equipment problems, primarily on the secondary side of the plant, have delayed some startup activities, overall equipment and personnel performance was very good. The licensee's performance assessments conducted at all milestones through 100% power, as well as the NRC's inspection activities, have found no significant performance issues.

SMM Discussion:

The senior managers discussed the recent Commission decision to recategorize Millstone Unit 3

. as a Category 2 plant. The senior managers focused on the sound operator and equipment l

performance during the Unit 3 startup and power ascension program. The senior managers l

L.

12 decided that Millstone Unit 3 would remain a Watch List Category 2 facility. The senior managers did not review considerations for decreasing or maintaining the level of agency 1

attention at Millstone Units 1&2 given their current Category 3 standing. [Due to the licensee's subsequent decision on July 21,1998 to cease power operations at Millstone Unit 1, the Commission, in an SRM dated July 22,1998, directed the staff to no longer list Millstone Unit 1 as a Category 3 facility.)

The senior managers discussed the transition plan associated with NRC's oversight of Millstone.

Specifically, the Special Projects Office functions would be merged into the line organization.

Oversight of inspection activities would be retumed to Region I and oversight of licensing activities, including the activities related to the employee concerns program and safety conscious work environment, would be returned to the NRR Projects organization. Oversight of the ICAVP process would remain with a distinct organization reporting to NRR's Associate l

- Director for Technical Review.

CLINTON Backaround information:

Clinton Power Station was first discussed during the January 1997 Senior Management Meeting due to an overall decline in plant performance during 1996. The decline was clearly

' demonstrated in September 1996 events associated with a reactor recirculation pump seal failure which revealed significant deficiencies including problems with procedural adequacy and adherence, the degree of rigor in conducting operations, and engineering support to operations.

l Based on the results from the January 1997 SMM, Clinton Power Station received a trending letter.

The licensee's poor performance in operations continued during the next six months. A number of procedural adherence violations continued to occur in addition, similar poor performance was noted in radiation protection. While the material condition of the plant improved as a result of a concerted effort by operations, maintenance, and engineering staff, surveillance program weaknesses and inattention to detail during maintenance activities continued to contribute to equipment performance problems. Furthermore, weak engineering support for the station, incomplete and untimely root cause evaluations and corrective actions, and design errors hindered equipment performance.

During the June 1997 SMM, NRC senior managers were concerned that the licensee had not developed a comprehensive response to the NRC's January 1997 trending letter. While the licensee had implemented a number of short-term corrective actions, it had not developed a long-term approach to address performance deficiencies. It was not clear to the senior managers that the licensee had a full understanding of the depth and scope of the reasons for the performance issues at Clinton. Therefore the senior managers determined that allowing the licensee to perform an Integrated Safety Assessment (ISA), in lieu of a DET, was an appropriate approach to better understand the reasons for its performance decline and develop applicable long-term corrective actions.

i l

1

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13 The licensee conducted an ISA from August through October 1997 to review its performance.

The NRC reviewed the effectiveness of the ISA with a Special Evaluation Team (SET). The ISA i

identified significant weaknesses in the areas of operations, engineering, maintenance and plant support. _ The SET confirmed the ISA's findings and determined that the root causes of these problems were:

4 management's inability to establish and implement effective performance standards programs, processes and procedures did not consistently provide defense in depth to assure plant activities were conducted in a safe manner

.. problem identification was inconsistent and evaluation and corrective actions were generally ineffective j

management did not ensure that the infrastructure was suitable to support major l

changes l

During the January 1998 SMM, NRC senior managers were concemed with the lack of progress by the licensee in developing a comprehensive plan to address performance deficiencies.

Despite being shutdown for a considerable length of time, there had not been substantive progress made in addressing the major performance issues at Clinton.- NRC senior managers were also concerned with the licensee's continuing problems associated with procedural inadequacies, a cumbersome work process, operator performance, and ineffective self-assessment act.ivities. Following the January 1998 SMM, Clinton Power Station was placed on the NRC Watch List as a Category 2 plant. In January 1998, PECO Energy was selected by l

lilinois Power to provide management services for Clinton for the next 3 years. Since that time, most key managers at Clinton have been replaced.

Based upon the findings of the SET, ISA, other NRC inspection activities, and licensee self-assessment activities, the new management team engaged the facility staff in developing a Plan For Excellence. Some progress towards performance improvement has been observed in the early implementation stages of the Plan For Excellence. The operations department was L

reorganized and operator performance has generally improved over the past six months. A System Design and Functional Validation of 5 systems was performed to address design control questions. A new corrective action program was implemented and problem identification has improved with the new program. The corrective actions for electrical breaker issues are nearly complete which has allowed the licensee to complete work to make electrical divisions I and 11 operable for the first time since August 1997. In addition, a major plant modification is well underway to address the degraded voltage concern at Clinton.

While some performance improvement has been noted, it has been inconsistent in some areas and is not yet self-sustaining. While there were improvements in conservative decision-making, there were isolated instances where operators engaged in activities that distracted them from monitoring the plant or where operators did not appropriately respond to abnormal plant indications. The licensee is struggling with managing the large backlog of condition reports and u

many problems remain unresolved. The preventive and corrective maintenance item backlog has grown during the extended outage and remains large. Progress in correcting material condition issues has been slowed by newly identified and recurring material condition problems.

For example, main control panel deficiencies were reduced to approximately 50 items in August

'1997, but work prioritization weaknesses led to an increase of over 200 items in the subsequent

l l

14 months.. A new work control process has been implemented, but is not yet effective in ensuring proper prioritization and accomplishment of work.

j Performance improvement initiatives addressing these and other areas are contained in the Plan for. Excellence. The plan has been developed through a robust process and implementation has begun; however, to a great extent, the Pl <. remains to be fully implemented and requires continued monitoring.

!=

l SMM Discussion, t

The senior managers considered the Watch List removal matrix in determining the appropriate i.

agency response to the identified performance concems. In reviewing the Watch List removal matrix, the senior managers focused on the numerous criteria that the plant had not yet '

l achieved. The senior managers discussed the licensee's organizational changes and decision l

to extend the shutdown in order to complete human and hardware improvements, such as those I

associated with the electrical breaker and degraded voltage concerns. It was noted that while management oversight at the facility nad improved and a new comprehensive recovery plan and corrective action program had been developed, equipment condition and human performance i

l problems continued to surface since the last SMM, indicating that these programs were still in

' the early stages of implementation. NRC performance indicators revealed several concerns

-l including long-standing design issues. The senior managers determined that there was a continued need for high level NRC attention at this site.

The senior managers decided that Clinton would remain a Watch List Category 2 facility.

LASALLE Backaround Information:

l LaSalle was given a trending letter in January 1994, due to concems about poor radiological work practices, declining material condition, declining personnel performance, and NRC staff ll concems about the licensee's ability to pursue and resolve root causes for these issues. By January 1995, the licensee's initiatives were found to be effective in arresting these adverse trends and the licensee was sent a letter informing them of this observation and urging the continuation of improvement initiatives. Improvement in plant material condition and engineering

, effectiveness was limited during 1995 and the first six months of 1996. The significant amount of emergent work and difficulties in planning and executing work hindered progress in L

implementing the station material condition improvement plan during the last six months of 1996.

In June 1996, a risk-significant event occurred involving the injection of large quantities of expandable foam sealant into the safety-related service water tunnel. The NRC issued a

$650,000 civil penalty to the licensee for violations associated with this event. Following the January 1997 SMM, LaSalle was placed on the NRC watch list as a Category 2 facility.

Both units at LaSalle have been shut down since September 1996 to address a variety of human performance deficiencies and hardware problems. In response to a number of performance issues identified by the NRC and through licensee self-assessments, the licensee developed a i.

I 15 comprehensive restart action plan.

During the January 1998 SMM it was noted that overall performance at LaSalle had shown signs of improvement commensurate'with the status of the Restart Plan. The licensee's efforts had resulted in improvement in several areas, although the improvement was not yet consistent and continued focus was considered necessary to sustain the improving trend. The licensee had made improvements to the corrective action process and management at LaSalle had made a substantive effort to identify its material condition problems through system reviews. NRC L

senior managers noted that the plant was still immersed in an extensive shutdown, with a substantial amount of work left to be accomplished. Additionally, a large portion of the Watch List removal matrix items had yet to be completed or assessed.

Since the last SMM the licensee has continued to implement the programmatic changes described in its Restart Plan. Improvement has been noted in the licensee's ability to identify L

problems and determine root causes. Licensee self. assessment activities are raising i

performance expectations. ~ Additional improvement is needed in ensuring appropriate implementation of corrective actions.-

Many material condition improvements and design changes have been completed to correct design deficiencies, operator workarounds, temporary alterations, and degraded equipment. A l

number of the modifications have been extensive and are indicative of management's commitment to fix long-standing equipment problems; however, the scope of identified material L

condition problems that the licensee plans to resolve following restart remains a concern.

Various engineering programs, such as setpoint control, fuse control and inservice testing still l

have work remaining. The adequacy of management oversight and assessment of the aggregate effect of the material condition and design conformance issues remains a concern.

' Supervisors and operators received training to address human performance errors and personnel performance has improved in all areas. Activity level at the plant continues to increase as the licensee approaches the planned startup date of July 28,1998. An NRC restart '

readiness inspection has been scheduled prior to startup to evaluate licensee performance during a more challenging period. The NRC Oversight Panel continues to hold public meetings with licensee management.

SMM Discussion-I The senior managers considered the Watch List removal matrix in determining the appropriate agency response to the identified performance concems. Although the licensee is making

. significant progress toward resolving historical performance problems, particularly in correcting

(.

material deficiencies, improvements are still in the early stages and have not been in place long i

enough to be either assessed or self-sustaining. Desired improvements in operator l

performance, including procedure adherence, have not yet been fully demonstrated and the l

ongoing procedure upgrade program has not been completed. Consistent and effective root

. cause analysis still relies heavily on oversight organizations. Substantial non-outage maintenance backlogs remain and will not be reduced until after restart. Both units have remained shut down since September 1996 and thus sustained, successful plant performance has not yet been demonstrated.. Also, as a result of the extended outage on both units, l

?

d 16 performance indicators provide limited insights regarding performance trends.

The senior managers decided that LaSalle would remain a Watch List Category 2 facility.

i Category 3: Shutdown Plants Reauirina NRC Authorization To Ooerate And Which The NRC i

i Will Monitor Closelv i

i MILLSTONE 1 & 2 (Please refer to the Millstone 3 discussion above.)

Note: In July 1998, the senior managers did not review considerations for decreasing or j

maintaining the level of agency attention at Millstone Units 1&2, given their Category 3 standing.

On July 21,1998, Northeast Nuclear Energy Company submitted a letter stating their decision to cease operations at Millstone Unit 1. In an SRM dated July 22,1998, the Commission directed the staff to no longer list Millstone Unit 1 as a Category 3 facility.

l Trending:

Plants Receiving a Trending Letter D.C. COOK Backaround Information This is the first time D.C. Cook has been discussed at the SMM. The SALP report issued on March 19,1998 indicated a significant decline in licensee performance in the area of engineering. An NRC Architect Engineering (A/E) team inspection, conducted from August 4 through September 12,1997, resulted in the identification of significant weakness in design control and several design basis issues. After further review of these issues, the licensee identified that the units operated outside the design basis on multiple occasions and determined that several safety systems were inoperable including the refueling water storage tank, residual l

l heat removal system, and portions of the service water, instrument air and component cooling water systems. The installation of fibrous material inside the containment and the potential blockage of ventilation holes in the containment recirculation sump which could have rendered the emergency core cooling system inoperable, two issues that were identified through NRC inspection, also exemplified the engineering program deficiencies in design changes and licensing basis reviews. The licensee shutdown both units to address the concerns revealed through the Architect Engineering inspection.

j Performance in the area of operations remained relatively good with improvement noted in I

control room command and control due to increased management attention. In the area of maintenance, some improvements were noted in procedure quality and adherence, identified as problem areas during the previous P! ant Performance Review assessment. However, as noted above, the material condition of the plant degraded to the point where the operability of some safety systems was questionable. Performance in the area of plant support was good but some problems were noted with radiation worker practices and security force performance. NRC

t V.

l l

17 inspectors continued to find examples of the licensee's failure to understand and control the design basis of the plant and the failure to provide quality engineering support to the facility.

Examples included the failure to update the Final Safety Analysis Report regarding the design basis of the containment ice condenser, the failure to follow the established design control process for ice condenser modifications, and the failure to implement prompt corrective actions

' for ice condenser conditions adverse to quality.

On March 7,'1998, the licensee implemented a Restart Plan that required system engineering reviews /walkdowns of 21 risk significant systems. Findings from these walkdowns are reviewed by the System Engineering Review Board (SERB) to determine which issues constitute restart items. The SERB assessments are reviewed by a Restart Oversight Committee for approval of restart items. The Restart Plan activities are assessed by the Senior Management Review Team (SMRT). The !icensee also instituted functional area, programmatic, and containment assessments. The containment assessment was initiatad in response to the NRC inspection L

findings specific to containment related systems. The other assessments are an extension c '

the system reviews and are designed to ensure a broad assessment of plant systems, processes and procedures.

SMM Discussion The senior managers considered the following factors in determining the appropriate agency response to the identified performance concerns:

ARGUMENTS FOR MAINTAINING CURRENT AGENCY ATTENTION Effectiveness of Licensee Self-Assessment l

l'

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A Senior Management Review Team, a Restart Oversight Committee and a System Engineering Review Board have been established to oversee self-assessment and deficiency correction activities A number of initiatives were implemented to identify and assess plant programs and safety system problems including design reviews, system evaluations, and functional area assessments These initiatives have resulted in comprehensive system and process review that revealed problems that require resolution prior to plant restart

' Appropriate plant staff has been trained in conducting effective self-assessments, identifying root causes and correcting deficiencies Operational Performance (Frequency of Transients)

Overall, plant operation was good as indicated by the low number of plant transients and operational events Before the dual unit shutdown, improvements in the area of operations resulted in better control room command and control, more consistent procedural adherence, and higher quality operating procedures Operations performance during the Unit 2 outage was also good

18 Human Performance Human performance exhibited improvement since the facility shutdown in l

September 1997-

~

Initiatives were implemented to reduce the number of contractor control and maintenance human performance errors The results of these initiatives indicated a decline in the number of personnel errors l'

L Material Condition (Safety System Reliability / Availability)

The material condition of plant systems th.at operate routinely was good l

Subsequent to plant shutdown, safety system walkdowns identified issues requiring attention prior to plant startup Work Control System enhancements are being made to address process inefficiencies j

i l

Engineering and Design j

Licensee reviews and assessments following NRC inspections have identified the L

breath and depth of engineering problems Actions are being taken to address design control process bypasses that resulted in a loss of design control Initiatives including functional area assessments and independent design reviews are in progress to improve engineering support to plant organizations l.

ARGUMENTS FOR INCREASING CURRENT AGENCY ATTENTION I

Effectiveness of Licensee Self-Assessment I

Historically, self assessments identified procedural adherence and adequacy i

problems, but missed the broader scope issues Initiatives implemented to address broader issues are identifying problems that

- were not known by the NRC or the licensee Since the dual unit shutdown, the large number of identified plant problems is challenging plant staff, the work control process, and corrective action systems Operational Performance (Frequency of Transients) l Both units have been in extended shutdown since September 1997 Several operator errors resulted in minor plant transients that were attributed to procedure adequacy and adherence problems Recent operator training failure rates and NRC identified weaknesses indicated tnat performance had declined I

4 i

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19 l

Human Performance Personnel errors attributed to the control of contractors needed attention r

Surveillance procedures need upgrading Material Condition (Safety System Reliability / Availability) l

' Material condition of some safety systems had degraded to the point that i

operability was questionable Initially, the NRC identified a majority of the significant safety system issues and 1

NRC intervention was necessary to ensure broad corrective action was taken L

Problems identified with the work control program necessitated programmatic

. changes to improve efficiency l

Licensee system assessments have continued to identify a number of problems that impact material condition and require repair or replacement prior to restart Engineering and Design l

Engineering support to plant organizations has not been effective:

L Calculations to support engineering decisions were weak or in error,

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j-Safety evaluations were poor and could not be supported by existing documentation Numerous processes existed that bypassed the design control process l

The consequences of the ineffective engineering support and design control L

process resulted in questionable operability of several safety systems Independent design inspection of the containment spray system also identified design and performance problems I

g Actions to address the poor design control process have only recently been L

implemented t

p

. The senior managers discussed NRC's inspection efforts at D.C. Cook and the design issues that had been identified.since the August 1997 A/E inspection. Of particular note were the significant material condition problems associated with the ice condenser, which led to the plant's operation outside of its design basis and the extended shutdown of both units since September 1997. While overall performance in the areas of operations remained good, significant safety system deficiencies were identified during the period. In addition, weaknesses in the licensee's 50.59 and self-assessment processes were noted.

The discussions of the senior managers primarily focused on the risk significance of the

- engineering and design issues identified at D.C. Cook. Specifically, the deficiencies associated

- with the ice condenser, the containment recirculation system, and the containment hydrogen abatement systems were of particular concern to the senior managers. The senior managers also noted that the performance indicators and LER data revealed a declining performance trend in the first quarter of 1998. The senior managers acknowledged the risk significance of the containment deficiencies and other material condition problems identified in the PIM.

L i

o 20 The senior managers concluded that the licensee and NRC may in fact not understand the extent of problems at D.C. Cook. While it was initially thought that the problems may be limited to the engineering and surveillance areas, the senior managers decided that additional information was necessary before such an determination could be validated. NRC response to 1

the licensee's ongoing programmatic and functional area assessments and plant system i

verification reviews was discussed and senior management concluded that special inspection activities are warranted in these areas.

The senior managers acknowledged that there has been a slow decline at this facility for some time and that, combined with the risk-significant engineering issues at the site, there is a need to communicate this decline to the licensee. Thus, the senior managers agreed that a trending letter was appropriate to convey the agency's concerns with D.C. Cook's recent performance.

Other Plants Discussed:

QUAD CITIES Backaround Information:

Quad Cities was first discussed at the June 1991 SMM and at each SMM since June 1993 with the exception of the June 1997 SMM. Following the January 1994 SMM, the NRC sent the licensee a Trending Letter to express concern over the continuing decline in overall performance. After the June 1994 SMM, the NRC sent the licensee a Follow-up Trending Letter expressing continuing concem. During the first half of 1995 overall performance improved.

Following the June 1995 SMM, NRC managers concluded that the declining trends at the Quad Cities Station had been arrested. During 1996, Quad Cities displayed slow improvement in operations performance, material condition, procedural adherence, trending, and accountability.

The last SALP period (report issued January 30,1998) found the conduct of nuclear activities at the plant to have declined. The plant was discussed again during the January 1998 SMM. The senior managers agreed that a trending letter was the appropriate regulatory tool to convey the agency's concems.

The Unit 2 was shutdown on September 27, and Unit 1 on December 20,1997, to address concems regarding the ability to safely shutdown the units in the event of a fire. A Confirmatory Action Letter (CAL) was issued to the licensee in January 1998 concerning the fire protection (Appendix R) issues. Over the course of this assessment period substantial problems were identified with the procedures for 10 CFR 50 Appendix R Fire Protection, in service inspection (ISI) and in service testing (IST) programs, understanding and application of the design basis, operability determinations and 10 CFR 50.59 evaluations, continued missed surveillance testing, and untimely and inadequate corrective actions. The licensee has begun broad based corrective actions to improve these areas. AltNugh the effects of the corrective actions are not fully realized yet, much improvement has been noted. On May 22,1998, the improvement efforts culminated in closure of the CAL and the licensee subsequently began startup of both units. These efforts put a significant strain on licensee staff, and there has been an increue in employee tumover. There have also been numerous management changes since December l

1997 including the BWR Vice President, Site Vice President, Station Manager, Engineering

21 Manager, Maintenance Manager, and Quality and Safety Assessment Manager.

Operations generally performed well during this assessment period although there were some

' equipment configuration problems, mostly due to errors by non-licensed operators, some of which impacted the reliability and operability of the emergency diesel generators (EDGs).

Operations staff was involved in several missed technical specifications surveillance through January 1998. However, much improvement has been noted in this area with no missed surveillance since February. Control room demeanor and operator knowledge continued to be good. On June 27 and 28,1998 respectively, Units 1 and 2 each scrammed from full pcwer.

The Unit 1 scram was due to a failed level switch occurring while a % scram signal was inserted for surveillance testing. The Unit 2 scram was caused by an electrical perturbation due to severe weather.

Maintenance work performance was generally adequate, with some exa'mples of deficien' work t

resulting in the need for rework. Although the plant material condition was generally good, there were repetitive maintenance issues. The emergency diesel generators were all rendered.

inoperable due to continuing problems with time delay relays. There were also examples of I

poor oversight of contracted work, and recurring examples of maintenance processes not adhering to vendor recommendations. The licensee continued to miss technical specification surveillance. As an example, the source range nuclear instruments on both units had to be declared inoperable due to a failure to perform the required functional testing. However, improvement has been noted in this area with no missed surveillance since February. In response to numerous deficiencies identified by the NRC in the licensee's ISI and IST programs, the licensee performed their own audit of the program and is addressing the findings by rebuilding the program.

Weaknesses in engineering continued to involve the lack of understanding and application of the design basis, operability determinations and 10 CFR 50.59 evaluations, and attention-to-detail in calculations. Substantial programmatic problems with the application of 10 CFR 50.59 were i

identified by the licensee following NRC identification that the licensee conducted a hydrostatic test of the reactor vessel and primary system boundary after core criticality in violation of 10 CFR 50 Appendix G requirements. The licensee has initiated several design basis initiatives and an FSAR review. Engineering has applied a majority of its available resources to resolving the fire protection safe shutdown issues. Some positive efforts have been noted in the licensee's ability to meet commitments and improve their system failure analysis.

Overall performance in plant support, except fire protection, remained generally good and unchanged from the previous assessment period. The licensee allowed high levels of L

contamination in some areas of the plant and overall station dose was high. Other attributes of the plant radiation protection program were good.

l In several cases, the licensee's self-assessment activities were effective in identifying problems, however, resolution of the findings was weak in some cases. The licensee properly detected a problem with mixing different kinds of grease in the station blackout diesel generator, but did not follow through in making an operability decision until questioned by the NRC inspectors.

Corrective actions for previous EDG start failures were not tracked to completion. Also, problems identified at the Dresden station were not always adequately addressed at Quad

(

22 Cities. Licensee initiatives included identifying numerous problems with the Quality and Self Assessment organization, implementation of an improved corrective action program, human error reduction training and the use of scorecards to improve human performance.

SMM Discussion:

The senior managers considered the following factors from the plant performance evaluation template, in determining the appropriate agency response to the identified performance concems:

ARGUMENTS FOR MAINTAINING CURRENT AGENCY ATTENTION L

Effectiveness of Licensee Self-Assessment

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l l

June 1997 assessment of Maintenance Rule implementation provided a clear set f

of major issues. Corporate assessment in 1998 was thorough and entire program was revamped. Maintenance Rule follow up inspection concluded all requirements were met.

l-January 1998 assessment of 50.59 program was thorough and identified programmatic breakdown. Improvement program was implemented.

Assessments of ISI and IST were thorough and identified multiple problem areas.

i Improvement programs were implemented.

l Multiple Fire Protection safe shutdown procedure deficiencies were identified. All safe shutdown paths were declared inoperable and Unit 2 was shutdown early.

Unit 1 was subsequently shutdown in December. New Safe Shutdown Analysis -

i and implementing procedures were developed.

Quality and Safety Assurance organization has taken an active role in improving the performance of the corrective action program Operational Performance (Frequency of Transients)

Good dual unit operation in 1997.

~

Restarts following lengthy outages for both units in May 1998 were carefully

' planned and controlled.

Operator response to plant conditions in 1997 was good with complex evolutions handled well.

Human Performance Operator performance in 1997 was generally good, with transient responses, startups and shutdowns handled well. Operator performance during the restart of j

l

)

l 23 both units in May 1998 was essentially error free.

Maintenance personnel generally performed tasks safely and in accordance with j

procedures.-

1 Good worker performance in Plant Support.

Material Condition (Safety System Reliability / Availability) t Material condition was generally adequate and supported 2 long periods of dual unit operation in 1997.

I Maintenance backlog has been reduced and ability to get work done has been demonstrated.

l Permanent fixes to many of the known equipment problems were aggressively pursued in preparation for restart.

l Engineering and Design Committed to perform in-depth system design reviews.

An Engineering Assurance Group (EAG) was established to review engineering products and upgrade the quality of engineering work.

Substantial resources were applied to the resolution of fire protection safe j

shutdown pathway issues. A new Safe Shutdown Analysis and implementing procedures were developed. The Confirmatory Action Letter was closed in May 1998.'

Training and in-line performance of 50.59 evaluations by the EAG were implemented to improve safety evaluations. Appropriate, successful hydrostatic 1

tests were completed on both units in 1998.

ARGUMENTS FOR INCREASING AGENCY ATTENTION Effectiveness of Licensee Self-Assessment i

Resolution of 1997 self-assessment findings on Maintenance Rule was untimely and inadequate, September 1997 inspection concluded worst implementation in Rill.

Assessment of 50.59 program and ISI/IST programs were prompted by several instances of poor implementation such as Appendix G hydrostatic test after.

criticality.

. IPEEE showed fire to be a high risk contributor and a large number of operator

24 l

actions were necessary, yet procedures for fire protection safe shutdown were inadequate. Resolution of fire protection issues had received low priority.

Extensive NRC intervention was needed for complete resolution of the issues.

Compensatory actions were still needed.

The corrective action program lacked rigor and thoroughness. As a result, I.

identified problems were not adequately addressed and existed for long periods.

l l-Operational Performance (Frequency of Transients)

Minimal operating performance data because both units were in an extended outage until May 1998 (Unit 2 shutdown in September 97 and Unit 1 in December 97).

l O,:erating and operability decisions were weak in some cases in 1997, such as entering shutdown LCOs to perform maintenance.

]

l Human Performance Operations staff was involved in several missed Technical Specifications surveillance.

1 Personnel errors, mostly by non-licensed operators increased slightly and some resulted in unintended changes in plant configuration.

Maintenance errors resulted in unnecessary radiation exposure and incorrect reassembly of seal ring type valves.

. Multiple weaknesses in system knowledge, understanding the design basis, and attention to detail in calculations hindered individual performance in wgineering.

Material Condition (Safety System Reliability / Availability)

Preventive maintenance and corrective actions for electrical breaker problems was untimely and inadequate.

Emergency diesel generators have had marginal auto-start reliability.

Several repetitive equipment problems have existed for an extended period.

Engineering and Design Design basis information was not easily retrievable or lacking in quality. Some calculations were missing.

Staff change out and diversion to fire protection issues limited the effectiveness of the Engineering Assurance Group.

1

)

(*

l:

25 l

All Fire Protection safe shutdown paths were inoperable due to procedure I

discrepancies. Unit 2 was shutdown from September 97 to May 98 and Unit 1 from December 97 to May 98 because of reliance on opposite unit equipment, incomplete Safe Shutdown Analysis and inadequate implementing procedures.

L Compensatory measures are still necessary to ensure cafe shutdown.

L Poor safety decisions, inadequate 50.59 screening, and poor understanding of the ASME Code led to hydrostatic test of the reactor vessel at power instead of prior to criticality in June of 1997, in violation of 10 CFR 50 Appendix G. The quality of inspection performed for the test was also inadequate.

j

' The senior managers noted observations of mixed plant performance since the last SMM. Both units at Quad Cities restarted at the end of May after a long dual-unit outage to reestablish

. Appendix R safe-shutdown paths. Subsequent to the restart there were several power

' reductions and two scrams due, in part, to material condition issues. While operational l

. performance demonstrated improvement since the extended outage, operations personnel were involved in several missed Technical Specification surveillance. Also, while the material L.

condition of the plant improved and the maintenance backlog was reduced, there were maintenance errors and concems with emergency diesel generator reliability.

The Quality and Safety organization took an active role in improving the performance of the corrective action program; however, a lack of rigor resulted in the licensee's failure to address some long-standing issues.~ lt was also noted that the engineering organization appeared to be burdened by efforts to resolve Appendix R issues. The sense of NRC senior managers was that Quad Cities performance was mixed with slow improvement in some areas. While a decline in

. some performance indicator trends was detected, the senior managers determined that there L

were not sufficient operational data or inspection insights available to assess the overall

(

performance trend at Quad Cities. Furthermore, it was not clear that Comed's efforts had L

resulted in measurable performance improvements at Quad Cities. Consequently, the senior l

managers determined that it would be prudent to observe Quad Cities performance for a longer i

period of time to assess the performance trend.

-)

i The senior managers discussed the IPE and IPEEE associated with Quad Cities. Specifically, the senior managers noted that the IPE shows a low estimated core damage frequency for intemal events of 2.2E-6/yr. The IPEEE Core Damage Frequency was reported to be SE-3/yr L

due to fires.. Fire initiators in the turbine building dominated the risk profi!S. While the licensee has subsequently taken compensatory actions to reduce the fire CDF by 6.ddressing the fire l

l-

. protection safe shutdown pathway issues, long-term corrective actions are still underway and l

remain an area of NRC focus.

The senior managers could not conclude that the adverse performance trend had been arrested at Quad Cities due to the limited operational data since the last SMM.

l4 i

j-26 INDIAN POINT 3 Background Information:

Indian Point 3 (IP3) was placed on the NRC Watch List in June 1993 as a result of a

_ erformance decline that was attributedto weak management processes and controls, weak p

' ndependent oversight, and a growing volume of plant deficiencies and operator performance i

errors. The plant entered an extended shutdown in February 1993 and did not restart until June of 1995. Additional material condition problems emerged, necessitating an extended maintenance outage in the latter part of 1995; The plant was 'again restarted in April.1996, and 3

L has operated fairly consistently since that time, with a few extended outages to address some.

material condition deficiencies as well as a refueling outage from May to September of 1997.

Based on overall improvement in site performance and indications that the improvements would i

h i

. cont nue, t e sen or managers removed IP3 from Category 2 of the Watch List in June 1997..

L l

. Since the last SMM, performance at IP3 continued to improve, albeit slowly in some areas.

Overall, the licensee operated the plant conservatively, and operational performance improved as indicated by fewer transients and forced outages. The plant operated continuously since the last SMM.' Human performance at the plant was good, as indicated by a personnel rate that was

- maintained below the established station goal.

Equipment performance improved since the last SMM. Equipment modifications and enhancements contributed to fewer equipment failures and operator challenges. The service water piping replacernents and control room air conditioning modifications increased the

respective system's reliability. The licensee made progress in reducing the non-outage backlog by about 30E The reduction of backlog was indicative of improvements in the work control process.

Slow improvement was noted in the area of engineering. The engineering organization contributed to the identification and resolution of several design deficiencies. The licensee 4

. continued to implement engineering improvement plans and programs, such as engineering backlog reductions and engineering work process improvements. The licensee's motor operated valve program was cound and was an indication of improvement in long-term engineering programs, la contrast to these improvements, problems with equipment -

L modifications and inadequate documentation of some operability determinations and engineering resolutions were sometimes evident.. One notable example was an inadequate modification which adversely affected the motor control centers that supported two of the emergency diesel generators

.There continued to be a good'self-assessment capability throughout the organization and a conservative operating philosophy. The quality assurance organization continued to make

~

notable contributions to the identification of deficiencies.

SMM Discussion:

The' senior managers discussed the status of Indian Point 3. The senior managers noted that l

x 27

- lP3 performance remained acceptable and continued to improve. The senior managers acknowledged that progress has been slow, but that it is continuing. It was noted that continued close monitoring of IP3 by the region will need to continue, but that agency-level attention is not warranted. The senior managers noted that IP3 will not be discussed at the next SMM.

l Additional Topics Discussed:

l

1. EDO's Ooenino Comments l

The Executive Director for Operations (EDO) welcomed the senior managers in attendance and

- noted that there were some vital discussions related to the SMM process that would take place during the SMM. He emphasized that significant changes in the SMM process were likely in the coming year. He noted that Chairman Jackson had recently been inducted in the Women's Hall of Fame, an honor for both her and for the NRC.

2.' Chairman JacksormBemarks e

Congressional Activities The Chairman summarized the concems raised by the Senate Appropriations Subcommittee regarding the NRC's oversight of reactor facilities. Specifically, the concerns raised were 1) the need to end over-regulation,2) the need for the NRC to move to more risk-informed, performance-based regulation, and 3) the need to change the assessment process for reactor facilities. The Chairman discussed her tasking memorandum recently issued to the staff to respond to these concems. The Chairman reiterated that this was an opportunity to call attention t

to the progress made to date by the agency and to address concems that are valid. She noted that there is a hearing before the Senate Authorization Committee on July 30,1998. She also challenged the senior managers to reflect on whether the call for change represents a

)

L fundamental rethinking of activities or an acceleration of activities that are already ongoing.

l e

Communication.

l=

.The Chairman discussed the recently completed OlG Cukure Survey and what the results should represent to agency senior management. Specifically, the managers should be concerned about the survey finding that employees believe their ideas are not valued by agency menagemen;. The Chairman challenged the senior managers to demonstrate to the staff that l

they are receptive to ideas. She also reiterated the importance of breaking down the barrier that l

currently hinders the sharing of information between agency senior managers and staff. The l'

Chairman emphasized that the agency needs to improve its internal communication and benefit i

from the insights of a very talented staff.

e

' Inspection Program The Chairman emphasized the need for improvements to the reactor inspection program. She noted that stakeholder are calling for changes in the way we inspect and for reductions in our inspection efforts. Agency senior managers will be meeting with these stakeholder on July 17,1998, to further discuss their concems about the inspection program. The Chairman noted

l f

28 that the agency has already embarked on initiatives to improve the efficiency and effectiveness of its inspection process. She challenged the senior managers to ensure that as the inspection process changes, it remains linked to safety. In order to do that, the inspection process must l

become more risk-informed.. She shared her vision for a risk-informed baseline inspection process.

Performance Assessment Process :

The Chairman challenged the senior managers to continue with its efforts to improve the reactor performance assessment process. She complimented the staff's efforts to date to utilize more objective data in the assessment process. She noted that the staff's IRAP initiative was an exemplary attempt to revise the assessment process and is a product upon which to build. She noted that the Commission recently approved SECY-98-045. However, the Chairman reiterated that the assessment process must become more risk-informed and must be more consistently implemented. The clarity of the agency assessments must also be enhanced. The Chairman shared her vision of the reactor performance assessment process and how the public (industry and general) perceives the safety of nuclear plants.

e

. Senior Management Meeting Process -

)

The Chairman noted that the Commission, in its staff requirements memorandum issued in response to SECY 98-045, directed that SMMs be conducted on an annual basis in the future.

The SRM also directed that the results of the SMM be provided to the Commission for negative l

consent. Finally, the SRM directed that enforcement not be the prime mover of the assessment j.

process. With respect to enforcement, the Chairman noted that the agency's assessment process must be safety-focused and results-based.~ While enforcement is an important input to assessment, the assessment process must take a broader look at licensee performance. The Chairman reiterated that the change to annual SMMs does not preclude the senior managers from meeting more frequently, for example, to ensure the inspection and enforcement processes are being carried out consistently. She stressed that the decision by the Commission to require negative consent on the SMM results in no way reflects a lack of confidence in NRC senior

. managers. Rather, the decision reflects the significant importance of the SMM assessment results and is a step in enhancing the scrutability of the SMM process. Furthermore, the Commission has historically had a de facto option of changing SMM results as demonstrated by the Commission's 1996 decision to change Millstone from a Category 2 to a Category 3 facility.

_d

'a '

l 0

l l

l ATTACHMENT 2

. Senior Management Meeting Watch List -

t Removal Evaluation Factors Clinton Crystal River 3 Dresden 2 & 3 LaSalle 1 & 2 l

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