ML12192A504

ROI, Case No. 4-2010-061

ML12192A504
Person / Time
Site:	San Onofre
Issue date:	01/20/2011
From:	Langan S J NRC/RGN-III
To:	Collins E E NRC Region 4
References
FOIA/PA-2012-0010 4-2010-061
Download: ML12192A504 (18)

Text

CASE NO. 4-2010-061 R "** **United States Nuclear Regulatory Commission Report of Investigation SAN ONOFRE NUCLEAR GENERATING STATION 2 Failure by I (b)(7ZC) Ito Follow Procedures During Equipment Restoration Following Maintenance ,Office of Investigations Reported by OI:RIII in0ormatian in this record was deleted"';n *c~d e wt the Fr~ed0 in accordance with t Act, January 20, 2011 MEMORANDUM TO: Elmo E. Collins, Regional Administrator Region IV FROM: Scott J. Langan, Director Office of Investigations Field Office, Region III

SUBJECT:

SAN ONOFRE NUCLEAR GENERATING STATION, UNIT 2 -FAILURE BY)(7)(c)

ITO FOLLOW PROCEDURES DURING EQUIPMENT RESTORATION FOLLOWING MAI NTENANCE (CASE NO. 4-2010-061/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, NRR)yr.Distribution:

s/f (4-2010-061)

DOCUMENT:

S:\OI\FY201OCASES\Closed Casjes-, -(b)(7)(c)

"""S a g n "-7r NAME SLangan DATE ) O/2011 01R CO /2011 OFFICIAL RECORD COPY

\oFF9IA U~ N~01Oi EST GATION 3 J(TN Title: SAN ONOFRE NUCLEAR GENERATING STATION 2 FAILURE BY E(b)(7)(c) 0 FOLLOW PROCEDURES DURING EQUIPMENT RESTORATION FOLLOWING MAINTENANCE Licensee: Case No.: 4-2010-061 Southern California Edison Company P. 0. Box 128 San Clemente, CA 92674-0128 Docket No." 05000361 Allegation:

RIV-2010-A-0079 Reported by: Report Date: January 20, 2011 Control Office: OI:RIV Status: CLOSED (b)(7)(C)-" .) ISpecial Agent Office of Investigations`.

Field Office, Region III Scott). Langan, Birnet Office of Investigations Field Office, Region III.'O\NOT DISSEMI&ANTE PLACE IN THE PU8LIC OCUMENT ROOM, 0 DISCUSS THE 9ONTENTS ,F THIS REPORT OF INVESTIG TION OUTSIDE NRC /ITH9OT AUTHORITY OF/THE APP OVING OFFICIAL OF TI'uS REPORT/UNAUT ZED DISCLO'S$URE ,AY RESUL N ADV .SE ADMINIS'iATIVEý,CTION AND/OR CRIMINAL'FROSECUTION.

.AFFIC IA U ab -01IN ESTIG TIO NFO MATIQN SYNOPSIS This investigation was initiated by the U.S. Nuclear Regulatory Commission, Office of Investigations, Region IV, on June 9, 2010 to determine whether _(b)(7)(C) 1(b)(7)(C) willfully violated established procedures in the wiring of a terminal board at the San unotre Nuclear Generating Station (SONGS).Based on the evidence deveclnnd, this investigation did not substantiate the allegation that (b)(7)(C) willfully violated established procedures while wiring a terminal board at SON6S.ýNOT'FQ PUBUC HOUT APPROVAL OF FIELDýFTE 0FCE TO OFF-ICI OF INESTIGATIONS\,,REGION

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TABLE OF CONTENTS Pa~qe S Y N O P S IS ..........

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......... 1 TESTIM O NIAL EVIDENCE .....................................................................................................

5 DOCUM ENTARY EVIDENCE ................................................................................................

7 DETAILS O F INVESTIGATION

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9 Applicable Regulations

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9 Purpose of Investigations

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9 B a c k g ro u n d .............................................................................................................................

9 Coordination with NRC Staff ..............................................................................................

9 Coordination with Regional Counsel ................................................................................

10 Testim onial Summ ary .......................................................................................................

10 A g e n t's A n a ly s is ....................................................................................................................

14 C o n c lu s io n ............................................................................................................................

1 4 L IS T O F E X H IB IT S ...................................................................................................................

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F R IEG O F GATIONS, REG NV Case No. 4-20'IU-Ubl].~OFCIA U~E~-OI~WE1~AION R TON OFF-) AL U 0 Y -IN SI T IN R 10 TESTIMONIAL EVIDENCE Exhibit (b)(7)(C)............

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....1 0 (~b)(7)C)

]Southern California Edison (SCE) ....................

11 (b)(7)(C ) I ..........................................

.12 11(b)(7)(C ) IS C E .............................................................

1 3 (b)(7)(C)(b)(7)(C)

I1 b ) 7 ( )I ....................................... 15

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,O'~FlCIA 41S J- ~ G.AT1 INF RMATOz)N\DOCUMENTARY EVIDENCE Apparent Cause Evaluatfinn (ACEFI rb)(7)(c)-I r )(7)(C) [outlines the fact finding}-iuuutea Dy lcensee personnel into the main transformer breakers becomina tri The conclusion noted human error on the part of (b)(7)(c) f (b)(7)(C)

[(b)(7)(C)

]and (b)(7)(C) caused the incident (Exhibit 3).Nuclear Notification (NN 7 D)(7)(C) jinitiatea tne Human Factors and Prompt investigation on the incident (Exhibit 4). -)....Unit 2 Work Order (b)(7)(c)

Rework (C)1 remove equipment/wiring with a scheduled start date, (b)(7)(C) outlined the work eingcompleted by 1 b)(c landP L'Thli Within the work or per, form S0123-11-15.3 (commonly referred to as 1x3h wincluded and contained the initialed off work performed by(b)c and d(rb)e(f) (Exhibit 5).Prompt Investigation Report of NN (bI (7(c) dated (TXc) outlined information gathered by the licensee relative to the attempted start o (b)(7)(C) and corresponding breaker becoming tripped (Exhibit 6).General Procedure S0123-XV-20, Verification Practices, Revision 3, effective date August 7, 7 .2009 outlines the licensee rocedural verification practices.

These practices are directly related to the work assigned to nd[(b)(7)(C) (Exhibit 7).Instrumentation Procedure SO123-11-15.3, Temporary System Alteration and Restoration Form, Revision 17, effective date April 17, 2009 outlines the licensee instrumentation procedures for-C. an independent verifier.

This procedure is directly relevant to the work being performed by b)(7)(C) jand 1(b7)(C) VExhibit 8).NRA Procedure S0123-XXX-3.8, Potential Deliberate Noncompliance Evaluations, Revision 0, effective date March 30, 2010 outlines the licensee procedural expectations in the review of potential deliberate noncompliance events. This procedure was relevant to the review conducted by licensee personnel on the case matter (Exhibit 9).Agent's Note: The wirina conduc-ted rnd(b)(7)K(C) 11,,, e on....70. )(7)c) .._ By the time',.(b)(7)(c) was completed the above listed procedure was in effect." FOR PUB CLOSU E THOUT P OVAL OF ID OFF RECT Case No. 4-2010-061 OFFICIAL US ....NL...I eSTIkATIOyWF ATI

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/NTFOR PIB L'IC DIS0 , R/E WITHOUýT ROV`AL OF F\IEýL OFFICE D TGE\I-7-- OFFICE OF INVESTIGATIONS, REGION IV Case No. 4-2010-061 8"OFFiCIAL USEflt Oi-O 01YSIGTOA$~M

/UFICISE LY -01 S DETAILS OF INVESTIGATION Applicable Regulations 10 CFR 50.5, Deliberate Misconduct (2009 and 2010 Editions).

Technical Specification 5.5.1.1.a, Written procedures shall be established, implemented and maintained.

Regulatory Guide 1.33, Revision 2, Appendix A, Maintenance of safety related equipment should be performed in accordance with written procedures.

Purpose of Investigations This investigation was initiated on June 9, 2010 by the U.S. Nuclear Regulatory Commiss (NRC), Office of Investigations O Re 4. ieterrne whether (b)(7)(C)and ý (b)(7)(c)

_7 with Ib)(7)(C)e ue yvolated established procedures in t e wi ermina oar at the San_nofre Nuclear Generating Station (SONGS).Background On April 29, 2010, Southern California Edison's (SCE's) SONGS, San Clemente, California, notified NRC:RIV of the identification of potential willful misconduct by (bxTxc I f~b=7)(cL-

ý According to the licensee, during an attempt to start a(b)(7)(C)

..,..F(o)(7)(C)

[the breaker tripped immediately due to a differential over-current.

SONGS advised that during the investigation, they determined that the over-current was caused by a wiring discrepancy on terminal board "TB," where it was found that the first two of three connections were not per the drawing (the wires were connected 2, 1, and 3 instead of 1, 2, 3), which caused 7 to attempt to rotate in the opposite direction for which it was designed.SONGS reported that a Human Factor and Prompt investigation determined that during the restoration of the wires, the i(7iClid not actually check the leads to ensure that they were corrlctly landed on rminal block. SONGS added that [(b))(C) (I initialed-off the work without actua cngte p acement Qf the , res con rary o instrumentation procedure S0123-11-15.3.

The o (b(7)(C)(b)(7)(c) working withj(b)(c)

Iwas identified as[b)(7)(c)" ONGS performed a willfulness review and documented the incident in Nuclear Notification 1(b)(7)(c)

{(Exhibit 1).Coordination with NRC Staff On June 8, 2010, the RIV Allegation Review Board (ARB) convened to review this matter which was provided by personnel at the SONGS lant. The ARB requested OL:RIV to initiate an investigation as to whether (b)(c) ) "or willfully failed to follow procedures while wiring a terminal block in b7 .(Exhi i '2).Case No. 4-2010-061 9 OFFIC111 I. ONY N IEGTIG I INFO111: 10tlll Coordination with Regional Counsel This investigation was initiated with the concurrence of RIV Regional Counsel, that if substantiated, the allegation would be a violation of NRC regulations.

Testimonial Summary (bb)(7)(c) explaied he previously worked as a (b)(7)(C)

He acknowledged havin worked as a (b)(7)(c) duin 4h fi! ,' )ewhn t7e incidents under investigati DuriC ng(b)(7)(C)

--, the pre-job brief conducted by ((b(7)(C) e estimated the duration of the briefing to have been in the -minute r nge an escri e the briefing as routine in nature (Exhibit 10, pp. 3-4, 9-10).:understood (1 and ........ had previously completed "Temporary System Alteration and Restor " (form 15.3) which were utilized in conjunction with the work in--5l7b)(7) ]7.explained his understandinof m verify e quired a worker to look at t item in question.

It as acknowledged () athat s7)(c) aS conducting the wiring and b)(i)(C) was the individual who was to have ye-e e wires were installed in the correct manner. (b)(7)(c)

Jdisavowed training was an issue in the incident."They jQ7)fc) _are (b)(7)(C)

I Any time I ever verified something, I lookedat it, you know, and verified that it's one, two, three. I mean how much training do you need to verify something" (Exhibit 10, pp. 14-16).Several questions were directed atl c jas to whether1mm or had willfully violated procedures.

F7A)(C) twas identified as having more for the incident as he documented that he vtT the wiring when he did not. P(b7Xc disavowed knowing.t rt ocedural lapse was willful or ineptitude.

ine -terviewing agent noted to (b)(7)(C) jthat during a review process at the plant, it had been concluded that there had teenca willful aspect to the procedural violation.

E c J "noted, "I can't say what he)(b c) as thinking, but I do think he should have looked at it, if he's going to sign that he leVT Jt (Exhibit 10, pp. 20-22, 30).-7cjn7c noted as a. T'I(xii~ 1, pp. 3"-35.'fb)(7)(C) xI 1 pp. 32P.35 ISCE, advised she had spent the last(F777)(b)T)(C) eat the SONGS plant. She explained in January 2008 the 7 NK; issued aconfirmatory order reaiiing the plant "to prevent and detect willful violations.'

An action from the order was to implement a monitoring program wherein events at the plant were screened or evaluated for willfulness.

SCE procedure SO-123-XXX-3.8 was identified as the procedure implementing this process (Exhibit 9; Exhibit 11, pp. 3-5, 7).NNZ7)(0) with a creation date was reviewed with I )(7)C IShe noted that during the course of the Apparent Cause Evaluation (ACE) it was surmised that "a potential deliberate noncompliance" had occurred and in accordance with procedures, was tasked to conduct a willfulness evaluation (Exhibit 4; Exhibit1 1, pp. 8-12).

OSURE ITHO AP OVAL 9 FtDOFF E RE R OFFICE OF I TIGATIO IREGION IVT"" Case No. 4-2010-061 10 ICIAL FO OFFICIAL USE ONLY -O11 NVESTIGATI OWNFORMATO 1J noted from her understanding of the events, procedures and training had been adeute. Upon checking with the worker's peers, it was understood "verification means to-ok at each of the wire numbers, before signing." (recalled I(b)(7)(C) nd stated they trusted each other and therefore had no c ecked eacý-other's work (Exhibit 11, pp. 18-20).

she coordinates the evaluation of incidents he corrective action plan for willfulness.

She stated the verification form initialed byl 7)(c) without having looked at the c. wiring, was a conscious or willful act of noncompliance. (b)(7)(C) understood the workers did not feel it was necessary to check each other's work as they a een working with each other a long time (Exhibit 11, pp. 23, 26-27).CLj advised she did not believe either worker [b)(7)(c) or( had been entered into the Personnel Access Data System (PADS) system in a negative way because of the incident.She explained since the middle of 2008 the plant has reviewed events for willfulness because of the previously noted confirmatory order. Approximately 10 events from 320 have been identified as deliberate noncompliance (Exhibit 11, pp. 31, 34-35).I(bX(7)(C)

... )(7)( stated he had worked as a (b)(7)(C)during the appropriate time frame of He recalled working on Unit 2 at the plant and each shift included tour to eight workers (Exhibit 12, pp. 2-4, 6-7).On the day in question:((77FL) tated he and ( "were landing wires" for existing electrical lines. I b( )C) acknowleged he had connected electrical lines that day and initialed off as having pe ormed the line restoration.

F)cý advised in February 2010 (no specific date noted) he was contacted byf7F)(C)(no specic -individual noted) as "they wanted to get a better understad f what happ brie7nd the procedure for doing it." He did not recall who he met with from[:)5)

I(Exhibit 5, p. 57; Exhibit 12, pp. 9-14).k~b)(7(C)

I (b)(7)(c)= ]described having worked withI Jseveral times during the course of the outage and acknowledged having completed the Performed By column of the work nrdipr documentation while r(t)(77)(c--

completed the Verified By column. "His{(b)(7)(C) l job was to observe me ... we d-d ie-a positive verbal communications.

..I would verify, verbally verify the cable number, identify the cable we're going to land, and repeat that to him, and say, that's 7 C correct, and then he'd repeat it again ...he would say that, I would repeat it to him and he would verify that and repeat it again, and I would land that wire, and say okay, cable such and such, wire two, point two, and I would re eat t at to him, he would repeat it back to me, and so, it landed. That was the procedure. (b)(7)(C) tated both he and E)(7c) ead the wires incorrectly or inthe next month an aha other workers re-worked the wiring in the box, causing the trip. )(7)(C) was not aware of re-working having occurred, but noted, "it's a possibility" (Exhibi 12 pp. 15-19).( recalled any procedural training related to verification procedures would have consisted of a procedural outline being read. W(b)(7)(c)

Istated the form documenting the wiring work was completed on the night the work wa comple ed. He further described the work in I art as follows. "They were very narrow cabinets, only room for one person. So, the verifier (b)(7)(C)

I who was also doing the writing, stood behind me at the time. There were times when he was the restorer and I was the verifier.

Stood behind, read the cable number, positive verbal communication which cable we were working on, what terminal block we were working on, NOT FOR\PUBLf DISCLOSURE WITHOUT APPROVAL OF/FIELD OFFIRECTOR,.

' F"-.P........

OFFICE OF'INVESTIGATI6.NS, REGION ,..Case No. 4-2010-061 11 OFFICIAL USE ONL- -I INVE§3TJýATION INFORIMATION I

• / OUS ONLY -E0 and the location, and that's the way we working on, and the locations, and that's the way we handled our verification...

We felt we were following the procedure correctly" (Exhibit 12, pp. 20, 24-28).(b)(7)(C) advised the issue of verification was not covered during the pre-job briefing.X 7was identified as theb)(,)(c) who would have provided the briefing.

7)C 777-g-a not reca any environmental factors that impacted the work or any aspect of being hurried.7c 1tated, "We communicated clearly, we felt we were following the right steps to do the job, and That everything was moving smoothly" (Exhibit 12, pp. 30, 32, 35-36).1 (b)(C) Ireiterated from the time of the work being completed in November (2009) to the time the wiring issue became known in February (2010), man enla, were working in the cabinets.-. Upon further discussion of the procedural expectati on denied the understanding that F(M7 as required "to physically put his eyes on those wires (b)(7) as questioned as"o now h s peers understood verification required a visual confirmation.

He responded, "They must have had more experience with procedures at SONGS, that I did not have" (Exhibit 12, pp. 37, 42).The ACE as reviewed with ) particularly the section which summarized his interview-1c with L He noted in part "I'm not aware of the complete verification requirements

... I don't know what is necessary." (b)()(c) was not aware of any instances when L(b)(C)1 willfully violated procedures (Exhibit 3; Exhibit 12, pp. 45-47, 54).(b)(7)(C) advised upon an attempt to (.ý7)(C) .... -te re ays ripped an I knew that something was wrong with either the relay setting or e ' ne to the rel xplained in his position he would not have interacted with or known (b)(c) o (Exhibit 13, pp. 3, 5, 8).Upon review of ACE nd .)(7)(C) confirmed the paperwork would indicate thatb prerformed the wiring andl (b)(7)(c) lierified it. He described the"70. significance of the incident in part as follows. "The significance of the mis-wiring is the protection relay has a function to trip on differential and what that means is, when you give it power, if it sees any variance in the current, it will trip, and this wiring configuration it will trip instantly, because it's not receiving the correct phase" (Exhibit 13, pp. 11-13).F7advised he was not involved in completing the apparent cause investigation, but upon being contacted provided information about the even noted having attended and was-, involved in the prompt investigation of the incident.

1(b)(7) described the incident as "a lapse of judgment" (Exhibit 13, pp. 19-22).xz)(c) Jadvised he had worked at te SONGS R e time frame ofC)"-7c, noted he had worked at SONGS during an outage approximately 1 1/2years previously.

He denied having knowingly violated any procedures while workin at the SONGS plant. stated during the most recent outage he reported to q(7)(c j Exhibit 14, pp. 2-4, 7).(b7)(C)Irecalled on (c) 7he was working with.7)(C nd during the-7c. 'completion of work etermined "we re going to have to take these wires off." He further noted,"If you take the wires off ... you got to fill out these papers, the 15.3's and stuff, which we really N FORRE UWl i- APPRO ALF FIEDO F0 Case No. 4-2010-061FICA USE TI /" QFHCIAU E T"~I'AI.7 \S .>/

"'.,9 FFICIAL'UE ON4LY -0 IWSTIGA .O didn't know about." recalled he andi ]were working the ni ht ift and the area where the box was had thousands of connections.

He acknowledged (b)(7)(C) as attaching the wires to the box. "And as he attached them, I wrote them down, on this. As he --he would say, you know, 2XX-U242-A7 wire one, point one, and I would go okay" (Exhibit 14, pp. 8-9, 12-15).Ib)(JC) was questioned whether he looked at the wires. He responded in part as follows.hat where I have a really big problem now. We --because actually, we kind of knew that, but C(. we were not formally trained on that procedure 15.3 ... I don't remember reading it, but you know, maybe he's right, I don't know... I think if we would have been trained on that, specifically, on this procedure, this would have never happened.

But I still take --I got to take ownership because I verified" (Exhibit 14, pp. 16-17).F,777ýc Iadvised he wrote a statement as a part of the ACE. He noted having tried the best he could to outline what had happened, , denied having received the 15.3 policy prior to completing the work in question.

There was nothing noteworthy from the pre-job brief recalled bvl(b)(7I He noted thatl7b)(TC) said "nothing about 15.3's on this pre-job brief." PAIN) [acknowledged havig inioaled ff as having verified the wiring. "That was my fault, for not Ioo iing at it." He added, I "wasn't really trained" (Exhibit 14, pp. 18-20, 23-25).Upon further questioning (b)(7)(c) acknowledged he trusted (b(7)(c) an od nted that trust was a contributing factor as t, why he had not put eyes on te wiring. L .]advised if the other c) Junderstood they were required to put eyes on the wires prior to putting initials on the relevant documents they must have been trained. "I made a mistake. I didn't look at the log. I admit that. Plus I felti (bj(7j(c' felt confident in ) ork" (Exhibit 14, pp. 25-27).F(b)(e)(c)

-escribed having utilized three way communications with (7)(C) hen completing the documentation for the work. He again acknowledged not having oo ed at the wires.

also expressed the understanding that there would be "somebody checking the"7 =Zr i so as to ensure no disconnects occurred.

Theinter vwing agent again challenged ( as to whether he did not know on(b)(7)(C) .. hat he had violat ures.ýresponded as follows. I didn't know the fuprocedures and I relied on(c)1 (bX7)(C) lelectrical skills, too" (Exhibit 14, pp. 29-31, 33-37).-I Z advised there were no external factors (noise, time pressure, etc.) which contributed to the incident under investigation.

He reiterated this was the first time he had completed a form 15.3 and that had he received more training this would not have happened (Exhibit 14, pp. 38-41).(b)(7)(C) , advised shortly after l(b)(7)(c)

I (,b)(7)(C) he became aware of the situation and understood "there might be an issue with the wires." I (b)(C) explained he had taken part in a review of the incident as a member of a human perormance review board (Exhibit 15, pp. 3, 6, 9-10).As a Dart of the human performance review board proceedings, , Iwas interviewed.

j{b)(7)(c) }was there and we were talking to him about, did he understand the necessity of a yveriication, and he indicated the necessity of doing a verification, and he indicated that he did, but he wasn't really sure, because [he] wasn't (b) 7)TC) nd he{iOT FOR DISCL"OS3,RE WITHOOT APPROVAL F FIELD OFJCE DIRE TOR/,.,OFFICE INVESTIGATIONS, REG O.IV Case NO-4-2010-061 13 <., OFI I INFOAMTI 3ý"IL--8i OLY--..,VET AT -

qFfCIA USE LY -INV IGAý N I ORMA hadn't had the 15.3 training ...So I asked him, 'do you understand, you're required to do a verification'.

.. He told me, 'yes, I understand that.' So I asked him, 'Well why did you not do that?' He said, 'I had been working with this guy -my buddy for a Iongperiod of time and I trust him. I felt that he knew what he was doing and I failed to do my job."' 1(b)(T)c) -Ifurther 7c, explai h ecollections of b)(7)(C) Jassertions to the human performance review board."He l ()(c) 'ad, 'I know that -I understand what I did was wrong. I got that now. I don't feel like I had all the training I needed. I don't feel like I understood exactly what should have been done.' He was really unclear from -it appeared, from the directions that he was given" (Exhibit 15, pp. 11-13).r )(7)(xc) -tated he questionedJ(b)()()

Ias to the quality and detailed nature of the pre-job briefing.

1(b)(7){C) expressed uncertainty of what had been covered during the pre-job briefing, noted neitherC)( ) orI(b)(77c) 1(b)(7)(C)

• 7c and had Me Deen so, a better understanding of the requirements wouia nave been known.j(b)(7)(c) jmade the decision to terminate b)(c) " employment with ( ecause of a rprocedura.

violation, regardless of it being cwnsi ere willful or not. "I don" ink that he L 7)(C) Joutright willfully said, '1 just ain't going to do it.' I think there is [are] other factors, but I still tni tie's accountable for his actions" (Exhibit 15, pp. 13-17, 22-23).A-gent's Analysis as the lin charge of the work being performed oni I He expressed the view at the process of conducting verifications would require visual observation of relevant items. He declined to provide input as to whether or not the procedural

-7 c lapse was willful (Exhibit 10, pp. 14-16, 30). 1(b)7)C) linterviewed 0)(7c() las a part of the human performance review board shortly afte--(7)(C) tripped on He recalledlb)T}({c)be unclear of the precise procedural expectation (Exhibit 6; Exhibit 15, pp. 13). b}(T)c) -as a (b) (7) (C) ho oversaw the work order which outlined the work being done by(b)(7)() land 1 j7 J He described being involved in the prompt investigation of the event an c aracterized it as having been a "lapse of judgment" (Exhibit 13, pp. 21-22).b)(7)(c) ldescribed the rewiring work as being completed in cramped conditions and explained there had been a verbal verification of the work but not a visual confirmation.

He advised if other[(b)(7)(C) nderstood verification to require a visual confirmation then they must have had more experience or training (Exhibit 12, pp. 26-28, 42). JC)(I)(c)

]acknowledged having initialed off on the documentation without havin visually verified te'"wiring.

He explained utilizing three way communication with" fjyX J ut emphasized he did not fully know the procedural expectations (Exhibit 14, pp. 24-25, 29-31).The testimony and documents compiled during this investigation indicate a clear procedure violation.

However, evidence was not developed to conclude the procedure violation was done willfully.

Conclusion.sd on t evidence developed, this investigation did not substantiate the allegation that Sillfully violated established procedures while wiring a terminal board at SONGS.\~ 6R B:LIC7DIýSCIS6U WýITHOUT PRO L OF LD O\ýýICE EC ýOR,\ FCFICE OHI VES ATIONS, N IV Case No. 04 OFFICIA SE NLY -01 VE TIGATI IN RMWfl-I\

LIST OF EXHIBITS Exhibit Description 1 Investigation Status Record, dated June 9, 2010 (1 page).2 Allegation Review Board package dated June 8, 2010 (21 pages).3 ACQ 4 (b(7)(C) 1(42 pages).NN c j= cr4 to 12 pages).5Unit 2 Work Order F(b-)(7-)(C-)-

start date l(b)(7)(C) 159 pages).6 Prompt Investigation Report o 0')c) I datedH(,)(c) (C)l (4 pages).7 General Procedure SO123-XV-20, effective date August 7, 2009 (22 pages).8 Instrumentation Procedure S0123-11-15.3, effective date April 17, 2009 (8 pages).9 NRA Procedure S0123-XXX-3.8, effective date March 30, 2010 (12 pages).10 Transcript of Interview with (bX7)(c) dated August 5, 2010(39 pages).-7c 11 Transcript of Interview with&dated August 3, 2010 (36 pages).12 Transcript of Interview with (b)(7)(c) dated August 4, 2010 (59 pages).13 Transcript of Interview with dated August 4, 2010 (31 pages).14 Transcript of Interview ofwtf)(c) dated August 4, 2010 (43 pages).15 Transcript of Interview oft--c) /dated August 4, 2010 (28 pages).15 Tansrip ofIntevie of~b)7)(c daed ugut 4,201 (2 paes)Case No. 4-2010-061 15 oFFICIA SE 0 Y -