Monday Accident & Lessons Learned: Root Cause Analysis of San Onofre Nuclear Generating Station, Unit 2 & 3 Replacement Steam Generators
This certainly sounds like an expensive incident and you would think they would use a state of the art root cause analysis system. Instead, they used cause-and-effect. See the report and see if you agree that the “root causes” of the incident are:
I think the lessons learned is to get a better root cause analysis tool!