“Thank you, my name is David Fritch. I, uh, I'm a worker on the ISFSI project. I work in the spent fuel project – F-R-I-T-C-H. I do industrial safety, so OSHA stuff, not nuclear stuff, but I'm out there. And uh, I may not have a job tomorrow for what I'm about to say, but that's fine. Uh because I made a promise to my daughter that if no one else talked about what happened on Friday, that I would. About 12:30, August 3rd we were downloading, and uh the canister didn't download, but the rigging came all the way down. Uh, there were gross errors on the part of two individuals. There were gross errors on the part of two, two individuals, the operator, and the rigger, um, that are inexplicable. Um, so what we have is is a canister that could have fallen 18 feet. That’s a bad day. That happened. And you haven't heard about it. And that's not right. My friend here is right, public safety should be first. And I've been around nuclear for many years. It's not. Behind that gate, it's not. Here's a few things that I've observed in the three months I've been here. SCWE, um, the Safety Conscious Work Environment, where people are constantly, uh, given, um, encouragement to raise concerns. It's not repeatedly or even, I've never even received SCWE training since I've been on site. That's not standard for a nuclear site. Um, operational experience is not shared. That problem had occurred before, but it wasn't shared with the crew that was working. We're undermanned. We don't have the the the proper personnel to get things done safely. And certainly undertrained. Uh, many of the experienced supervisors, what we call uh CLS's, Cask Load Supervisors, once they understand the project and how everything works, are often sent away, and we get new ones that don't understand as well as even the craft, basic construction craft. And a lot of them who haven’t been around nuclear before are performing these tasks - not technicians, not highly trained, not not thorough briefs. Um, this is an engineering problem. What happened is, um, inside of that cask there's a guide ring about four feet down. And it's to guide that canister down correctly to be centered in the system. Well, it actually caught that. And from what I understand, it was hanging by about a quarter inch. So, obviously, the point is, uh clear. Um, as people said, Edison is not forthright about what's going on. I'm sure they'll tell you that they were going to bring this out once it was analyzed, etcetera, etcetera. I'm sure they're preparing what they would answer if it comes out. Um, and I came here tonight to see if this event would be shared with the community. And I was, I was disappointed to see that it was not. And I want to thank the community of San Clemente. It's a beautiful, wonderful community with amazing people. You’ve been great to me. My family’s here with me for the month. Um, and unless Edison and Holtec commit to defining success on this project as safety, and I'm not, I’m not talking about any of the concerns voiced today, I'm just talking about downloading – getting the fuel out of the building safely. Um, and, and, and are we going to address what would have happened to that canister if it would have fallen? Even if the shell wasn’t penetrated, now will, will they take it in a repository site? Um, the question is, will, will Edison and Holtec commit to defining success primarily in terms of nuclear safety. And there will there be transparency, commitment to safety, and the financial commitment to make sure that it’s done successfully. Thank you. “
|Union Tribune||2018-08-11||Incident with waste canister at San Onofre nuclear plant prompts additional training measures||External Link|
|Kpbs News||2018-08-11||Safety Inspector Describes Near Accident During San Onofre Community Panel Discussion||External Link|
|Citizens Oversight||2018-08-12||Citizens Oversight Calls Full-Stop and Thorough Safety Review at San Onofre after Near-Miss Incident||Local Link|
|David Lochbaum, Union of Concerned Scientists||2018-08-13||Dry Storage Issue at San Onofre||Local Link, PDF|
|Mission Viejo Patch||2018-08-13||Wedged Nuclear Waste Canister Raises Alarm At San Onofre||External Link|
|Nuclear Hotseat||2018-08-14||TERRORIST GROUP PLANTS DIRTY BOMBS ON So Cal BEACH – Oh Wait, That’s EDISON and HOLTEC at SAN ONOFRE! Whistleblower Reveals NUCLEAR DISASTER NEAR-MISS w/RADIOACTIVE WASTE – NH #373||External Link|
|East County Magazine||2018-08-15||CITIZENS OVERSIGHT CALLS FOR SAFETY REVIEW AFTER “NEAR MISS” SAFETY MISHAP AT SAN ONOFRE||External Link|
|Union Tribune||2018-08-21||Nuclear expert says recent San Onofre incident posed no threat to public — but says operators 'need to quit tempting fate'||Extrenal Link|
|Citizens Oversight||2018-08-21||Press Release: Citizens Oversight demands that Coastal Commission Investigate Near-Miss Incident at San Onofre||Local PDF|
|Citizens Oversight||2018-08-21||COPS letter to California Coastal Commission Regarding Near-Miss Incident at San Onofre||Local PDF|
|Nuclear Regulatory Commission||2018-08-24||Nuclear Regulatory Commission announced they will be conducting an inspection of the incident||External Link|
Dear David Lochbaum: Your slides cover a great deal of information that is unrelated to the scenario of Aug 3, 2018, but those are still informative nonetheless. Your slides do not show the exact scenario of getting stuck and they gloss over how the workers were able to recover. There was a good chance they would have missed the indications that it was not seated and may have moved the rig, thereby knocking it into the hole, resulting in the 19 foot drop. You did not analyze what might have happened, i.e. how the canister could have been knocked off the 1/4" precipice. I have some questions.
- You admit that the canister may have dropped 18 feet into the vault, but say that there would not have been a release. How do you know this?
- Has this scenario been modeled? (I.e. dropping 18 feet into the vault)?
- Would the canister deform at all?
- My intuition as an engineer is that the thin 5/8" shell may have deformed into the base of the cavity, and may have expanded so that it may not be easily removed. Do you have any evidence to refute my intuition? If that were the case, the cooling air may have been disrupted. Has this been modeled? Would the cooling, which is essential to cool these hot canisters been cut off and therefore the canister would likely overheat? But if it were stuck in the bottom and it was unable to be pulled back out, then what would be done?? No plans that I have seen for any scenario like this or frankly, of any other accident scenario.
- Has anyone actually tested the models with real-world tests of drops of fully-loaded canisters? Models are based on engineer's idea of what might happen. We already learned through bitter experience that the engineering design cannot be trusted, as the steam generators also were modeled and the models said no vibration would occur. In fact, in the SCE vs. MHI dispute, they determined that the models were incorrect, but even if corrected, those models would still not have predicted the vibration. I am sorry to say that i have very little trust in modelling by the nuclear industry to validate their own designs, and honestly, any trust that you may have is unfounded.
- It appears that the canister was teetering on the "MPC Guide Ribs" Do you agree that this a bad design if the canister can become stuck on those ribs?
- Why is there no additional means to observe the MPC canister being lowered other than having a worker look through the top and thereby be exposed to radiation? Has anyone thought that maybe a go-pro camera could be placed in that position to watch the canister being lowered and avoid the dosage issue?
- More than anything else, this incident has brought to light that there is too little transparency with what is going on. This incident was covered up for more than a week prior to the whistle-blower's statement, and he said this situation had been encountered in the past. This is a serious issue that is not dealt with in your slides. We would need to look at an organizational chart and see why this was not reported, and if it was, then why was this not divulged to the public at the CEP meeting?
Citizen Oversight Projects
Hello Ray: Plant owners are required to analyze a number of postulated fuel handling accidents including dropping an irradiated fuel assembly onto other irradiated fuel assemblies stored in the spent fuel pool, dropping a loaded spent fuel canister, and so on. The NRC reviews SCE's analyses. These analyses are described in:
These analyses are similar in scope and methodology of many other analyses that I've reviewed over 40 years at other plants. One of the analyses involves a scenario where a loaded canister is dropped 30 feet onto a flat surface. No crushing or other energy dissipation of the surface impacted by the canister is assumed; in other words, the canister and its contents incur the full force of the drop. The analysis concludes that some of the irradiated fuel inside the canister might be damaged and the canister might be damaged, but the integrity of the canister will not fail. While the 30-foot drop analysis should bound the 18-foot drop that could have happened in this case, Holtec is analyzing this specific scenario. A 25-foot drop of a loaded canister onto a flat surface was recently performed for either Callaway or Calvert Cliffs with the same results -- no breaching of the canister or release of radioactive contents. The 18-foot drop could have damaged the canister such that its contents would need to be transferred to another canister (at least the undamaged portions). The canister has 5/8-inch thick walls. But I'm told that its base is closer to 3-inches thick. Regarding transparency, the actual event did not have to be reported publicly. There are literally thousands of problems identified annually at operating nuclear plants. There are fewer problems reported at permanently shut down nuclear plants like San Onofre. Federal regulations have two parallel processes for identifying and reporting problems. Any problem having an actual or potential nuclear safety aspect must be entered into the company's Corrective Action Program (CAP) per 10 CFR 50 Appendix B. Since about 2002, NRC inspectors are required per their procedures to review the listing of all Corrective Action Reports and to follow-up on those of potential interest. Each Corrective Action Report generated must be evaluated for reportability under 10 CFR 50.72 (see NUREG-1022 for examples of what is and what is not reportable.) When an issue rises above any reporting threshold, the owner must notify the NRC within 4 hours and follow-up with a written Licensee Event Report (LER) within 60 days. The Idaho National Laboratory maintains a very useful search engine for LERs back to 1980 at https://lersearch.inl.gov/Entry.aspx It allows users to find and retrieve LERs by plant, by keyword, etc. This event tripped the 10 CFR 50 Appendix B trigger for initiating a Corrective Action Report. These are records internal to the plant owner but typically not available in NRC's ADAMS online library. The initiation of a Corrective Action Report would have required a reportability assessment. For several years, I conducted such assessments at the Browns Ferry nuclear plant. For a year, I taught reportability requirements to NRC inspectors and reviewers. This event was not reportable under 10 CFR 50.72. In hindsight, I get the sense that both SCE and Holtec would have preferred to pro-actively mention the near miss rather than having to react to it after Mr. Fritch revealed it. SCE and Holtec provided me some reasons for not doing so (work in progress, wanting to wait until all open questions were answered, etc.). But it clearly would have been better had SCE disclosed the event rather than have a worker do so. One final word on transparency -- the role and value of the Community Engagement Panel should not be underestimated. Most communities do not have such a panel. Which means that most communities do not have a comparable outlet for workers to raise safety concerns. In his remarks, Mr. Fritch spoke of concern that his raising issues could jeopardize his job (both SCE and Holtec have assured me that's not going to happen -- SCE is concerned that co-workers might not react well to his having spoken publicly and is taking steps to protect Mr. Fritch from any such backlash). Had Mr. Fritch not seen value in the Community Engagement Panel, he'd not have moved out on the tree limb. I asked SCE and Holtec about using cameras to monitor canister movement. Both are considering it. SCE mentioned that they are also going to examine the radiation dose that the spotter receives when visually monitoring the canister's movement. From how it was described to me, the spotter is not peeking over the top of the transport sleeve inches away from the top of the canister. The spotter is at an elevated position some distance away where a line-of-sight exists to the canister. But I had the same question as you -- why not use cameras. Cameras are so routinely used in so many applications that this one seems an equally fine opportunity to do so. SCE told me this canister was the 28th or 29th canister loaded and moved during the San Onofre Unit 2 and 3 dry storage campaign. There had been one prior event at San Onofre when a canister's bottom end rested on the CEC edge. Within the CEC and about two feet below the top is what is called the shield ring. It is installed to protect workers from radiation "shining" through that location. This ring is about five inches wide and about 9/16-inches larger diameter than the canister. The top side of the ring has angled metal welded to the ring and CEC's wall. These metal angles slope downward from the CEC wall to the inner edge of the ring. They function to center the canister as it is being lowered into the CEC. The canister on August 3 came to rest on two of the metal angles. Once the problem was discovered and the rigging raised to once again lift the canister, the worker moved the canister about two inches until it was properly centered to continue descending into the CEC. During insertion of an earlier canister, it also snagged on angled metal. In that case, workers quickly noticed the canister stopped moving and took steps to immediately free it and successfully lower it into the CEC. Apparently, this problem also occurred at another nuclear plant in the past year. These are likely the prior events that Mr. Fritch mentioned. SCE confirms that the prior events occurred and further concedes that the pre-job briefing for cask movements should have mentioned these events, what to look for, and what to do if one is detected. Holtec sent me two graphics -- one a drawn schematic of the CEC and the other a closeup photograph of the shield ring and metal angles. Holtec provided the graphics to me under the condition that I not use them publicly. I will look for a non-proprietary version of the schematic. This speaks to your comment about the MPC guide ribs design. The canister did not snag on the guide ribs -- it caught on the shield ring. But that's likely just semantics -- my initial take on the shield ring that a better design could avoid the trap that was sprung here and at least twice before. You raise a valid point about canister damage potentially adversely affecting the cooling within the canister. I already had an item on my To Do list to examine the potential impact of damaged fuel inside the canister. I was thinking about it from the standpoint that damaged fuel could pose re-criticality concerns. But you've identified potential cooling path blockage concerns. Thanks,
Hello Again Dave: I appreciate your kind response to my questions. I attempted to review your references and could find nothing to substantiate your claim that the containment boundary would not be breached. I also reviewed other documents. Please provide substantiation to your claim that the containment boundary would not be breached. Here are my notes.
Response by Ray Lutz to Lochbaum's references.
- https://adamswebsearch2.nrc.gov/webSearch2/main.jsp?AccessionNumber=ML16357A397 -- San Onofre 2&3 UFSAR Accident Analyses. Section 126.96.36.199 deals with Spent fuel cask drop accidents
- This section essentially says that the accidents are less than the 30-foot drop onto a flat, unyielding surface. The analysis deals with canisters with only 32 fuel assemblies (Holtec canisters hold 37) and it does not really deal with the drop inside the vault. The test of dropping a canister 30 feet is not provided.
- https://adamswebsearch2.nrc.gov/webSearch2/main.jsp?AccessionNumber=ML14092A332 -- This is the emergency exemption request from SCE to reduce accident scenarios.
- Does not deal with drop within the vault but only with the same accident of dropping inside the fuel handling building.
- https://adamswebsearch2.nrc.gov/webSearch2/main.jsp?AccessionNumber=ML15327A410 -- This has to do with the spent fuel island and has nothing to do with the spent fuel dry canister safety.
So far, I still have not seen any evidence to substantiate your claim. --Ray Lutz
- https://sanonofresafety.files.wordpress.com/2013/06/epri2013-12-17failure-modes-and-effects-analysissscanisters.pdf -- EPRI (2013) Failure Modes and Effects Analysis (FMEA) of Welded Stainless Steel Canisters for Dry Cask Storage Systems
- Does not deal with canister drops.
- https://inldigitallibrary.inl.gov/sites/sti/sti/3169747.pdf -- Drop Testing Of DOE Spent Nuclear Fuel Canisters
- Tested actual drops of spent fuel canisters weighing only 10,000 pounds and 24" in diameter x 15 feet long, filled with rebar to simulate spent fuel, 1/2" thick walls.
- These are only about 5 tons compared with 104 tons used at San Onofre, less than 5% of the weight.
- Canisters experienced marked deformation of the ends.
- https://inldigitallibrary.inl.gov/sites/sti/sti/3303759.pdf - Can Canister Containment Be Maintained After Accidental Drop Events? (2006 International High-Level Radioactive Waste Management Conference)
- Nothing new added here. The same tests from 1999 are reviewed. I notice significant end spreading in the vertical drop test and the ripple was far less apparent than in the finite element prediction, which should have raised red flags in terms of accuracy of the models. No attempt to extrapolate to larger canisters already in significant use in 2006.
|Title||Whistle-Blower David Fritch describes canister nearly falling 18 ft at CEP meeting|
|Note||CEP Meeting in Oceanside|
|Keywords||San Onofre Canister Drop Incident, Stop Nuke Dump|
|Related Keywords||Nuclear Waste, Shut San Onofre|
|Media Type||Article, Video, Meeting|
|Author Name Sortable|
|20180813-songs-ucs-dry-cask-transfer-event-1.pdf||manage||1 MB||2018-08-13 - 17:34||Raymond Lutz||Slides by David Lochbaum, Union of Concerned Scientists|
|ML110590883 - Preliminary, Qualitative Human Reliability Analysis for Spent Fuel Handling.pdf||manage||2 MB||2018-08-21 - 15:45||Raymond Lutz||Human Factors Engineering issues with spent fuel handling|
|ML14122A441.pdf||manage||225 K||2018-08-19 - 20:38||Raymond Lutz||PRELIMINARY SAFETY EVALUATION REPORT Docket No. 72-1040 HI-STORM UMAX Canister Storage System Holtec International, Inc. Certificate of Compliance No. 1040|
|2018-08-21 COPS Press Release on letter to CCC_v2.pdf||manage||422 K||2018-08-21 - 18:36||Raymond Lutz||COPS demands full investigation by Coastal Commission into near-miss incident -- Press Release|
|2018-08-21 COPS letter to CCC on San Onfre Events_v6.pdf||manage||710 K||2018-08-21 - 18:35||Raymond Lutz||COPS demands full investigation by Coastal Commission into near-miss incident -- Letter to CCC|
|IMPACT ANALYSIS OF SPENT FUEL DRY CASKS UNDER ACCIDENT SCENARIOS 25144.pdf||manage||836 K||2018-08-19 - 20:47||Raymond Lutz||IMPACT ANALYSIS OF SPENT FUEL DRY CASKS UNDER ACCIDENT SCENARIOS|