ML12192A503
| ML12192A503 | |
| Person / Time | |
|---|---|
| Site: | San Onofre  |
| Issue date: | 03/04/2011 |
| From: | Holland C NRC Region 4 |
| To: | Collins E NRC Region 4 |
| References | |
| FOIA/PA-2012-0010 4-2010-060 | |
| Download: ML12192A503 (17) | |
Text
IlL * *,.
CASE No. 4-2010-060 r
,J, United States Nuclear Regulatory Commission -~
r
- 4 Report of Investigation SAN ONOFRE NUCLEAR GENERATING STATION, UNIT 2:
FAILURE BY(b)( 7)(C) ITO PERFORM A PROCEDURALLY REQUIRED WALK-DOWN OR REVIEW OF TAGOUT BOUNDARY Office of Investigations Reported by 01:RIV ' e /
B, 4/6
ýý2
S,*:..:.... ,*:* ,Q2,.* ,. ..
- ..... *:: .. . v .:: %*.:*......:.. ": . :,...... ,-- = ; . ",*, -¶*-"* :_Z..2-Z*';.*z.. t:z::* ....
1-0 UNITED STATES NUCLEAR REGULATORY COMMISSION OFFICE OF INVESTIGATIONS FIELD OFFICE, RE GIO N IV
- 612 EASTLAMAR BLVD, SUITE 400 ARLINGTON, TEXAS 76011-4125 March 4, 2011 MEMORANDUM TO: Elmo E. Collins, Regional Administrator Region IV 9
FROM: Crystal D. Holland, Director_ 1.
Office of Investigations Field Office, Region IV
SUBJECT:
SAN ONOFRE NUCLEAR GENERATING STATION, UNIT 2 -
FAILURE BY A )7)(cITO PERFORM A PROCEDURALLY WALKAROWUIRD OWN OR REVIEW OR TAG OUT BOUNDARY (CASE NO. 4-2010-060/RIV-2010-A-0079)
Enclosed, for whatever action you deem appropriate, is the Office of Investigations (01) Report of Investigation concerning the above matter.
Please note that documents may have been gathered during the course of the investigation that are not included in either the report or the exhibits. This additional documentation will be maintained in the 01 case file and available for the staff's review upon request.
Neither this memorandum nor the report may be released outside the NRC without the permission of the Director. 01. Please ensure that any internal office distribution of this report is controlled and limited only to those with a need to know and that they are aware of the sensitivity of its contents. Treat as "Official Use Only - 01 Investigation Information."
Enclosure:
cc w/enclosure:
R. Zimmerman, OE cc w/o enclosure:
C. Scott, OGC 1&C E. Leeds, NRR (Attn: L. James, OAC, NRR)
M4arch 4, 2011 MEMORANDUM TO: Elmo E. Collins, Regional Administrator Region IV FROM: Crystal D. Holland, Director Office of Investigations Field Office, Region IV
SUBJECT:
SAN ONOFRE NUCLEAR GENERATING STATION, UNIT 2 -
FAILURE BY A(7)(c)TO PERFORM A PROCEDURALLY REQUIRED WALK DOWN OR REVIEW OR TAG OUT BOUNDARY (CASE NO. 4-2010-060/RIV-2010-A-0079)
Enclosed, for whatever action you deem appropriate, is the Office of Investigations (01) Report of Investigation concerning the above matter.
Please note that documents may have been gathered during the course of the investigation that are not included in either the report or the exhibits. This additional documentation would be maintained in the 01 case file and available for the staff's review upon request.
Neither this memorandum nor the report may be released outside the NRC without the permission of the Director, 01. Please ensure that any internal office distribution of this report is controlled and limited only to those with a need to know and that they are aware of the sensitivity of its contents. Treat as "Official Use Only - 01 Investigation Information."
Enclosure:
cc w/enclosure:
R. Zimmerman, OE cc w/o enclosure:
C. Scott, OGC E. Leeds, NRR (Attn: L. James, OAC, NRR) 7C Distribution:
s/f (4-2010-060) c/f (b)(7)(C) 'O l:HQ DOCUMENT: S:\OI\FY2010CASES\Closed Cases OFF"....IC E :: .I:R.-'- ,. ,'.. , '7" I.,"IV -. - .
"NAME "(b)(7)(C) CHolland--- I DATE ."o aE lo-/ I/
OFFICIAL RECORD COPY
Q,OFFICIAL -oNLY- O- INyVESTGAT NFOR N -.
Title:
SAN ONOFRE 2 FAILURE BY A (b)(7)(C) TO PERFORM A PROCEDURALLY REQUIRED WALK-DOWN UOKIvv UI- INALVuUT BOUNDARY Licensee: Case No.: 4-2010-060 Southern California Edison Report Date: March 4, 2011 2244 Walnut Grove Avenue Rosemead, CA 91770 Control Office: Ol:RIV Docket No.: 05000361 Status: CLOSED Allegation No.: RIV-2010-A-0079
.Re *ed by Reviewed and Approved by:
(b)(7)(C) pecia Agent Crystal. Holland, Director Office ot Investigations Office of Investigations Field Office, Region III Field Office, Region IV NOT DISSEMINATE, PLAýCE INHE PUBLIC .DODOU/MEN ROOM 0, DIS USS TH CONTENTS OF THIS REPO.RT OF I ESTIGATION.OUTSIDE NRC HOU AUTHO I'
.,OF TH/_APPROVING OFFICIAL OF TAIS REPORT. UNAUTH , ZED DISCLOU E MAY RESULT IN ADVF*SE*ADMINISTRATIV-ACTrON ANDIOR CRIMINAL PROSECUTION.
NF F R PUBLI DISC SURE WHOU APPRO Fl LD OFFIC DI , TOR, OF INVESTIG I ,REGIliLW OFFICIAL.4JSE 0 Y -O011 STIG TION INFO TI
,61 4USEkNL>/ýO NVt'16ATIO I/NF'Q ýATI SYNOPSIS This investigation was initiated on June 9, 2010 by the U.S. Nuclear Regulatory Commission, Office of Investigations, Region IV, to determine whether a )(7)(c) at Southern California Edison's San Onofre Nuclear Generating Station (SONGS) willfully tailed to conduct a procedurally required walk-down or a review of the tagout boundary while working under a Work Control Authorization.
Based on the evidence developed, the allegation that al (b)(7)(C) t SONGS willfully failed to conduct a procedurally required walk-down or a review ot the tagout boundary while working under a Work Control Authorization was not substantiated.
FIEL
(~T OR ih4IC DISýL'9SR
~ ICE VITUT APýRO\Al_ f Case No. 4-2010-060
..... \
- y-. . "
(*FFICIAL USE O>NLYOf"INVESTI WIN5MORAT THIS PAGE LEFT BLANK INTENTIONALLY NOT F9R P 13LIC DISCLOSURE WITHOU AP yIALF FIEL3.OEFiCE DIRECTOROFFICE*,F INVESTIGATI/ONNS, RE IV Case No. 4-2010-060 2 OF-FlMIAý ýEtLY --RI INVESTIP TION FORM 10
.,\,7 ./' /
OFFICIAL USE'ONLY * ./
- 01, INVETIGA ION IN.FORIkpON -,
TABLE OF CONTENTS Page SYNO PS IS ...................................................................................... I ............................. . . . . . . 1 T E S T IMO NIAL E VIDE NC E ......................................................................................................... 5 DOCUMENTARY EVIDENCE ................................................................................................. 7 DETAILS OF INVESTIGATION .............................................................................................. 9 Applicable R egulatio ns ........................................................................................... ... 9 P urpose of Investigation ......................................................................................... . .. 9 Ba c kg ro u n d ..................................................................................................................... 9 Ag e nts A n a lysis ............................................................................................ ... 9 C o n c lu s ion s ................................................................................................ . . . 12 LIST O F EXHIBITS .................................................................................................................... 13 I(NOT FOR PULC DISCLOSURE 4@ORT APPROV/
FIEJ.D OFFIC.E DI ECTOR, OPFFICE O5INVESTIG.ATIONS AEGION IV Case No. 4-2010-060
,,-.OFFIJi ONLY,.,'I IN STIGATIO9A O A K'. XFI-C)A 'OAS
THIS PAGE LEFT BLANK INTENTIONALLY
/N / .../
SNT FQR PU-LIC DISL:qOSRE WITHOUT APP OV 0 FILD FJE DIRE TIGATIO Case No. 4-2010-060 4 OFFJC USE OSI IN LTIGAON ýlIRMANl
6OIcIAL USE ONLY - OiNVESTIGA ION INFORMATION TESTMONIAL EVIDENCE Exhibit (b)(7)(C)
San Onofre Nuclear Generating Station (SONGS) ............................................................... 9
. .................................................... . . . 3 b)7(C IS O N G S ..................................... 8
!~ OT FOR UBLIC ISC OSUR WI OUT P OVA F
/FIELD FFWE OR, OFV FWINV ATIO Case No. 4-2010-060 5 _
OFPCI"L USEN-LY- INVESTICAT1 NINFO A0
- FFICl AL USE TIG TIQ ORR AON THIS PAGE LEFT BLANK INTENTIONALLY (ThTFO P LIC DlS0*REUWIT U PPROVA F FIELD O"FJG DIR TO FFICE I ESTIG ONS E V
?Fc,,CA O6,u L Case No. 4-2010-060 *- OhRSTG *_10**4 M ý
u01 UISE* *- N NT INFORMATIO DOCUMENTARY EVIDENCE Exhibit Section 6.3.5.3 of Work Process Procedure SO123-XX-5.1, Revision 18, d a te d O c to be r 16 , 2 0 0 9 ......................................................................................................... of Work Process Procedure SO123-XX-5.1, Revision 18, dated O cto be r 16 , 2009 .................................................................................................. .. . 5 No.i...a.....b..7..C................................... ......... 6 1)(C)7 ..........
7
/ F P LIC D CLOS E THOUT OVAL FIELD OF E ECTOR, E OF IN ESTI ATI S, GIO IV Case No. 4-2010-060 7 FM EIIN
/ CIA I SEENNLY - 0 INVE Q IG I ION OOFI MAT4 THIS PAGE LEFT BLANK INTENTIONALLY
/'NJOT FO UPBLIC DIS E WITH A" PROVLF FIIELD\OFFI* DIR CTOR,'OFFICE I_./Y*STIGATN ,
Case No. 4-2010-060
- NVESTA NF A ý X.
ORFICIL USE O
usI,,.N E IG
, 6NIN5 0RJY1 DETAILS OF INVESTIGATION Applicable Regulations Technical Specification 5.5.1.1.a Regulatory Guide 1.33, Revision 2, Appendix A, Quality Assurance Program Requirements 10 CFR 50.5, Deliberate Misconduct (2009 Edition)
Purpose of Investigation This investigation was initiated on June 9, 2010 by the US. Nuclear Regulatory Commission (NRC), Office of Investigations (01), Region IV (RIV), to determine whether 7(b)(7)(C) 'at Southern California Edison's (SCE)
San Onofre Nuclear Generating Station (SONGS), willfully failed to conduct a procedurally required walk-down or a review of the tagout boundary in the Unit 2 turbine building while working under a Work Control Authorization (WCA)[Allegation No. RIV-2010-A-0079](Exhibitl).
Background
On April 29, 2010, SCE notified NRC:RIV of potential willful misconduct by a (777) ]
b(7)(C) Ifor failing to complete a walk-down or review of the tagout boundary while working under a WCA. According to SCE, on or about b)(7)(C)
-(b)(7)(C) signed on to the WCA. According to SONGS' Procedure S0123-XX-5.1 ,(b)( 7 )(C) was then required t conduct a walk-down or a review of the tagout boundary, which he failed to perform. c ailure to conduct the required walk-down resulted in a breach of a pressurized instrument air line in the Unit 2 turbine building.
During the event review, the licensee became aware of cfailure to perform a walk-down and coMpleted a "willful violation assessment' of the issue. It was subsequently determined that
[(b)(7)(C) ]actions were a "deliberate noncompliance" of an NRC requirement. SONGS documented the incident in Nuclear Notificationc(b)(7)(c) 7 On June 8, 2010, the RIV Allegation Review Board (ARB) convened to discuss the information (7ryjded by SONGS. The ARB requested that OL:RIV initiate an investigation to determine if
.b) C) illfully failed to conduct the procedurally required walk-down or a review of the tagout L5~n ary (Exhibit 2).
Aaent's Analysis I(b)(7)(C) with determining whether an /
This investioation was tasked (b)(7)(C 1 willfully failed to perform a procedurally required walk-down or review of a ragout boundary (Exhibit 1: Exhibit 2). This event actually occurred oni linside the SONGS' Unit 2 turbine building when the plant was engaged in a riTuetlng outag E-x ibit 3,
- p. 33: Exhibit 7. p. 10). At that time, a modification to the instrument air system was in progress to replace a copper line with stainless steel. Specifically, a branch line was to be isolated, cut off from the old line and connected to the new stainless steel line (Exhibit 7, p. 9). According to 7~FO PU ICi'S U WI A Q ýVALF FIELD OFF,1 WECTOR, OFFI OF INV TION--EGIO-Case No. 4-2010-060 9 OM ONL ST, F M
0 8IAS ONLY IIESTIGATIO RMATIO N Section 6.3.5.3 of Work Process Procedure S0123-XX-5.1, titled, "Work Clearance Management Issue, Release and Tagging Modifications," Revision 18, the "Work Authorization Holder" (WAH) is responsible for ensuring the tagout boundary is adequate for team members' safety prior to starting the work activity (Exhibit 4). A walk-down would have accomplished this requirement since its ur ose was to verify a safe work boundary (Exhibit 5). Under this particular section,as responsible for performing this action since he was the WAH who had signed on to thVeWCA. The subsequent failure to verify a safe work boundary is significant because while installing the instrument air modifications, a welder cut into the pressurized air line.
AGENT'S NOTE: In a memorandum to file, dated May 26, 2010, RIV staff indicated that this incident was determined not to be a violation of NRC requirements because it occurred on a non-safety related system and had no actual consequence on plant operations (Exhibit 2, p. 6).
pt(b)(7)(C)
The licensee investiaated the event under Notification Number (b)(7)(C) ( Exhibit 6). '(b)(7)(C) NGS (b)(7)(C)
I Iwas taelled with determining wheer this event involvingt b) as a Category 7 noncompliance. In her 01 interview, (b)7)(C) "#xplained that pursuant to heNRC Confirmatory Order, a Noncompliance Review Panel (NRP) is normally convened after a "prompt investigation" reveals a "potential deliberate violation of site or NRC 7c, requirements." According tol(b)(7)(C) information from the prompt investation is obtained by the appropriate supervisors and/or managers and is provided to the NRP. 7 recalled the notification associated with the event and added that the questions on pages 6 and 7 of the document w~ered by others not affiliated with the NRP (Exhibit 6, pp. 6-11; Exhibit 8, pp. 6, 8-17). stated that the panel determined that based on the prompt investigation and the Root ause Evaluation there was deliberate noncompliance with an NRC requirement.
Specifically, the panel's decision was based on )(C) being aware of the requirement and cho ' ignore the procedure because he was oo busy" at the time. (b)(7) acknowledged tha tb)f( was never interviewed by her or anyone else on the NRP, and she cautioned that this determination was not the equivalent of a willful misconduct call by the NRC. (b)(7)(C) related that the purpose of the exercise is to bring to the NRC's attention an event at the site that is potentially willful (Exhibit 8, pp. 14-20).
I(b)(7)(C) I AGENT'S NOTE: A review of Notification irevealed that the elements leading to the NRP's conclusion aboutl(b)(7)(C) onsisted of 7c (b)(7)(c) answers to basic template questions concerning is knowledge and understanding of procedure requirements. However, the NRP did not consider mitigating circumstances which may have been identified during a thorough interview with the subject (Exhibit 6, pp. 6-11; Exhibit 8, p. 18).
o tir (b)(7)(C) Ine)(Cwa (b)(7)(C)
Lin cnarge fIn his) 01 interv tew, (C )*)relate dthat i Sen ine wasat IontheLý ý Of b"7(C) d hd ben n tatposition for aboutl(b)(7)(c) ' lre calle1-,
-7c. tthathe]J
[Accorc ing to--7)C)this involvetste~v'enrng an existing copper linethat was "tied-iniý to the pressurized line and replacing it with another instrument air line.
- ecie h entire process as "a new experience" since he and (b)(7)(C normally ha not worked on
,NOTNOR P,LIi&JC DISC,)-*r-OOU RE WzO ' OF ý FIE(D OFrI*..EIrIRECTO ,RFFICE OF INVES- TONSR Case No. 4-2010-060 10 OFF 2 Cl1AJ.SEGNqLY- Oll}N I.G-AfibN IN RMVATION
INFO MATION pressurized lines previously. On November 8, 2009,L was directed to double ch'eck and make sure that plant operations had given work clearance for a particular line. A "clearance" in this case is described as the main valves being closed off so that maintenance work could be (b)(7)(cdnstated that he checked the computer and verified that a clearance was in place.
(b)(7)(c) recalled that he was asked to do this because 1(b)(7)(C) was not familiar with the process. e expained that on the morning of (b)(7)(c) I he was given his turnover from his supervisor, (b)(7)(C) . and wa's I(b)(7)(C) 77":C (b)(7)(C) peopie .on .. (7- added that priorities dictate a certain activities needed to be 71 . completed within a time window i. addition to various other tasks. bb7 recalled that in the middle of his pre-job briefing with =(b7 ] another workerE(c) needed clearances for five ork pacdages. Each work package was assigned to a different pipe in the system. While (b)(7)(C bbtained clearances for each of the work activities, he admitted that he failed to issue (b)(7)(c) he walk-down forms that accompany the clearances. These forms, according to outline the boundaries for the work activity. These areas needed to be walked down prior to any work being conducted to ensure that it was safe. f()(T() contended that he knew that the )rpas needed to be walked down but he neglected to print out the walk-down sheets. I) 7 (CL Named this on being unfamiliar with the new computer system (Exhibit 3, pp. 3-19, 33). 4(b)(7)(C) icorroborated )7)c testimony, stating that the computer software used during the outage was new, and that thel(b)(7)(C) Iwere very busy at the time 1 1 (Exhibit 9, pp. 10-13).
(b)7))acknowledged that he signed on to the WCA and explained that it involved choosing among a computerized list of work orders having clearances and "clicking" on the roper order.
Once the work order is chosen, the user is "signed on" to the WCA. Accordin to (b)()c) by signing on to the WCA, he becomes responsible for the safety of 7Cadded (b7 that this included making sure h have an adequate boundary to work by walking down that area and ensuring that the valves are properly tagged (Exhibit 3, pp. 19-21). This is consistent with the aforementioned Work Process Procedure which defines a walk-down as: 1) "Picking up the Equipment Status List from Operations on the WCA ... of the items cleared;" 2) "Ensuring
'1rj. boundaries are sufficient for the work being done," and; 3) "Walking down all applicable items on the Equipment Status list, checking the tags and ensuring the proper position of the items and ensuring barricades, barrier tape, or warning blocks are properly used" (Exhibit 5). 1b)(7 (C) nitially claimed that he b 7c( but reneged. u n further questioning and admitted that he failed to communicate this request to him. ladded that he did not provide the walk-down sheets to (C) -- anyway, so(b(7(C) ' id not have the listed boundaries in his possession. )state that p ant operations ouine the valves and circuit breakers for each work order, and these are what needed to be reviewed. 17)(7) indicated that he was familiar with the site procedures associated with walk-downs an -un-erstood that the procedure was applicable under the circumstances. However,.E7c7ontended that he was "overwhelmed" with the multiple tasks and priorities that he neglected to perform the walk-down. The thought of conducting a walk-down or even lb)(7)(C) never occurred to him. When asked, rgued that it was a responsibility he overlooked, and it was not something he simply s rugged off (Exhibit 3, pp. 20-31).
Given the evidence in this case, (7C) violated the site procedure in that, as the one signing on
-7 to the WCA, he was responsible or ensuring a safe work boundp ,,Rpd this would be accomplished by conducting a walk-down of the area. AlthoughI1 b,)(C)]failed 1 to perform this walk-down, his mindset precluded willful misconduct. at 1clain his testimony that the j'NOTFORP LIC SCLOSURE T APPROVALOF FIELD OF4FICE-DIRECTOR, FFIC OfINVEST*ATIONS, ýE ION Case No. 4-2010-060 11 >
OFFICIALUSE ONL .,,O INVESTIGATION INFORMATION
OFFICIAL USE ONLY/OI INVESTIG "I 10 process involved in "tie in" work was a new experience for him and (b)(7)(C and he was not familiar with the computer system involved in the process. ( stated that because of his unfamiliarity with the computer, he did not print out the walk-down sheets. This did not help.i 7& reminding him of the walk-down or in (b)(7)(C) I According to he was overwhelmed with competing tasks and the thought of conducting the walk-down did not occur to him at the time. This would constitute negligence arising from forgetfulness and distraction. Because these factors are not elements of willfulness, the allegation thatZ(C) willfully failed to conduct the walk-down is not substantiated.
Conclusion Based on the evidence developed, the allegation that a ktSONGS t(b)(7)(C) willfully failed to conduct a procedurally required walk-down or a review of the tagout boundary while working under a Work Control Authorization was not substantiated.
/ . .,., . , / ,
,/ NOT. FOR PYBLIC DISCLOSURE WITHOUT APPROVAL OF .
fIELD OFFIQCE.DIRECTOR, OFFICE-OF INVESTIGATIONS,-REGION IV Case No. 4-2010-060 121/---
OFFICIAL USE'ONLY - 01 INVESTIGAT .I NFORMATION
OE.1LIAL USE-.ONLY- 01 INVESTIGATION INFORMATIOO \
LIST OF EXHIBITS Exhibit No. Description 1 Investigation Status Record, 01 Case 4-2010-060, dated June 9, 2010 (1 page).
2 ARB Summary and related follow-up, dated June 8, 2010 (9 pages).
3 Transcript of Interview with Jc]dated August 31, 2010 (48 pages).
4 Section 6.3.5.3 of Work Process Procedure S0123-XX-5.1, Revision 18, dated October 16, 2009 (1 page).
5 Attachment 2 of Work Process Procedure SO123-XX-5.1, Revision 18, dated October 16. 2009 (1 page).
6 NotificationI~b)( 7)(c) 1(11 pages).
(b)(7)(C) 77 Notification (b)(7)(c)
Notification 1(12 pages).
(12 pages).
8 Transcript of Interview withI7c9dated January 19, 2011 (24 pages).
9 Transcript of Interview with[ dated January 19, 2011 (20 pages).
rNOT1 DISC (OR*UBLIC URE WITHO APMOVALO R
FI.LD OFFC PD IRET*F F41 GATIoR AIT1E E ION I, Case No. 4-2010-060 113
,OFFtCIAL USi ON - 01 IN EST1GATION IN ATION