Missing Safety Documents at San Onofre Reactor – Troubling Consequences. (UPDATE – Found!)

Picture San Onofre Nuclear ReactorThe media has been reporting key missing documents at San Onofre Nuclear Reactor (SONR) related to safety and failing equipment (*)

I am deeply troubled and extremely concerned by this “lack of documentation”, as we should all be, especially for a critical life-threatening process involving critical failing equipment which is endangering plant reactor personnel, surrounding communities and the environment.


Apparently, for SONR there was a key part changed (tubes used in the process) that required a review and determination as to the safety risk posed and whether nuclear regulatory agency review and approval was required.  Apparently, the company made a determination not to involve the regulatory agency but documents supporting this conclusion are missing.  This is now a significant problem because this new equipment is failing which can endanger lives and the environment.

But it is now also extremely suspect that key documentation is missing, which casts suspicion on plant personnel and the company.

  • This is even more suspect because design review and approval changes are always done by a team of different departments and by different levels of plant personnel.
  • So several people at several departments should or could have a copy of the missing documentation.

My Audit Experience of Chemical Manufacturing Plants:

I audited chemical manufacturing plants and chemical engineering divisions for a large multi-billion multinational.  I traveled for about 3 years (traveling 95% of the time worldwide – primarily in the south of the US – Louisiana, Alabama, and Texas; and Chile, and Brazil, etc).  I traveled to 28 countries and 22 states.

A team of 4 or 5 of us would spend about 3 months doing a top-to-bottom audit of the chemical plant in question and then move on to the next plant.

I audited these plants to prevent a mechanical or process failure that could cause an explosion of the plant, or a release into the communities.  I would lead our team in weekly discussions with key plant personnel as to our scope of work, our status, findings, recommendations and key issues.  I audited according to:

  • Process Safety Management for chemicals (Title 29 CFR 1910.119 – Process Safety Management –PSM – of Highly Hazardous Chemicals).
  • We would also do a separate Environmental audit; and a
  • Separate Safety audit to comply with the company’s required EH& S (Environmental Health & Safety) annual audit and report requirements.  My employer company had also inherited a prior clean-up issue of a SARA (Superfund Amendments and Reauthorization Act) location (Love Canal).
  • I also reviewed and synchronized our company’s global EH&S CATTS (Comprehensive Action Tracking Trending System) program to stay updated on status of issues on our global chemical manufacturing plants.
  • Also with permission from our internal audit senior management, I would coordinate our reviews with plant personnel and also developed a relationship with the particular state’s equivalent of the EPA to determine and ensure the manufacturing plant was complying with our company’s and state’s environmental protection requirements.  This was a win-win for our company and the state’s citizens.
    • There were other times that our internal audit team had to push back, because some corporate management and some plant personnel wanted to push back on our compliance requirements because they argued we needed to make and take a “Business Cost-Effectiveness” attitude.
    • I said that if we already knew what the Best Available Technology, and the best available process was that we needed to follow, why would we abandon this, and run and increase  the company’s reputational risk and which could cost us more in the long run in lost lives, loss of a plant, or greater costs from after-the-fact  remediation efforts and/or plant shutdown.  I would ask, do you want to have headlines read “XYZ pollutes and kills people.”?
    • I would also half-jokingly reply, please tell us in writing that you want us to abandon our experience and our judgment and to use the FORD-Pinto Cost-Benefit (Negligence – Efficiency) analysis. Ford Pinto chose not to add about $11 to the manufacturing cost of a Ford Pinto even though they knew this would save lives from preventing gas tank explosions in an accident.



Although PSM for highly hazardous chemicals is different from the nuclear energy industry regulatory requirements (see Title 10 CFR for Energy Industry), I imagine that there are similar concepts that must be followed:

1) MANAGEMENT OF CHANGE Procedures (MOC) [ 1910.119(l)(1) ]
This guides the review and approval of DESIGN changes and is very rigorously documented.

2) MECHANICAL INTEGRITY  [ 1910.119(j) ]
Key/critical components in the whole manufacturing process are identified so that they withstand operations, do not fail, and do not cause a plan explosion or leak of dangerous gases or elements that can kill plant personnel, or others in surrounding communities.

Equipment under Mechanical Integrity category must be well maintained and any changes especially moving to use a NEW part (other than routine replacement with a previously approved part “for a replacement in kind”) requires review and approval under MOC procedures.

Evaluates the impact especially of the proposed Mechanical Integrity NEW PART being considered to be used.

For all of these steps, there are various levels of approvals in different departments.

This usually guides the retention and destruction of documents, and what typically happens is that companies/personnel may RETAIN documents LONGER than they are required (since they may forget to follow destruction procedures);

It is extremely rare that someone goes out and DESTROY key/critical documentation EARLIER than Required, especially MOC or Mechanical Integrity documentation, or one that is supposed to demonstrate why they have not increased safety risk with this design change.

5) DEVIATIONS [ 1910.119(d)(2)(i)(E) ]

An Evaluation of Consequences of deviations including those affecting the safety and health of employees.


SAFETY, SAFETY, SAFETY and DOCUMENTATION guides everything in a very regulated process.


So the regulators, the surrounding community, and even plant personnel involved in the process should be very concerned about this “missing” safety documentation because lives are at greater risk  and because SONR is known to be sitting on a new earthquake fault line.


Francisco “Paco” Barragán
For State Assembly 2012 – 69th AD
Business, Veterans, and Community leader

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(714) 605-2544 cell

(*) Picture Credit – Enformable

About Francisco Barragan