FERC After Action Panel - Assessment of Oroville Spillway Incident Causes and Recommendations to Improve Effectiveness of the FERC Dam Safety Program

This report was prepared by the FERC AFTER ACTION PANEL (FAAP). This Panel was convened by the FERC Director of Division of Dam Safety and Inspections (D2SI), Mr. David Capka, after the Oroville Dam spillway incident of February 2017 and given the charge to evaluate FERC’s dam safety program at Oroville during design, construction, and operations, including regional office annual site inspections, 5-year Part 12 safety review process and Potential Failure Mode Analyses (PFMA) exercises. Lessons learned during this review were utilized to develop recommendations to upgrade FERC’s review process at the Oroville Dam Project and for all other existing and future projects. This report also provides an assessment of the Root Causes leading to the February 2017 Service Spillway chute slab failure, the erosion downstream of the Emergency Spillway (ES) and provides comments on the DWR Independent Forensic Team (IFT) findings. As part of the process, the FAAP made an assessment of the FERC Part 12 process and DWR’s Owner’s Dam Safety Program (ODSP). We also reviewed how they were implemented at Oroville Dam prior to and during the February 2017 incident. These two items along with various interactions between DWR and the California Division of Safety of Dams (DSOD) form the bulk of the dam safety programmatic efforts at the Oroville Project. Finally, the FAAP provides suggested improvements for FERC to consider implementing in the existing Part 12 process. Our comments related to this part of the scope are not FERC After Action Panel Report 11/23/2018 Page 3 of 49 absolute in nature but are intended to generate a conversation leading to improvements of the processes in place for both the regulators and the dam owner/licensee.