started out with an examination of the accident at Three Mile Island
(TMI). This necessarily led us to look into the role played by the utility
and its principal suppliers. With our in-depth investigation of the
Nuclear Regulatory Commission (NRC), we gained a broader insight into the
attitudes and practices that prevail in portions of the industry. However,
we did not examine the industry in its totality.
Popular discussions of
nuclear power plants tend to concentrate on questions of equipment safety.
Equipment can and should be improved to add further safety to nuclear
power plants, and some of our recommendations deal with this subject. But
as the evidence accumulated, it became clear that the fundamental problems
are people-related problems and not equipment problems.
When we say that the
basic problems are people-related, we do not mean to limit this term to
shortcomings of individual human beings -- although those do exist. We
mean more generally that our investigation has revealed problems with the
"system" that manufactures, operates, and regulates nuclear power plants.
There are structural problems in the various organizations, there are
deficiencies in various processes, and there is a lack of communication
among key individuals and groups.
We are convinced that
if the only problems were equipment problems, this Presidential Commission
would never have been created. The equipment was sufficiently good that,
except for human failures, the major accident at Three Mile Island
would have been a minor incident. But, wherever we looked, we found
problems with the human beings who operate the plant, with the management
that runs the key organization, and with the agency that is charged with
assuring the safety of nuclear power plants.
In the testimony we
received, one word occurred over and over again. That word is "mindset."
At one of our public hearings, Roger Mattson, director of NRC's Division
of Systems Safety, used that word five times within a span of 10 minutes.
For example: "I think [the] mindset [was] that the operator was a force
for good, that if you discounted him, it was a measure of conservatism."
In other words, they concentrated on equipment, assuming that the presence
of operators could only improve the situation -- they would not be part of
After many years of
operation of nuclear power plants, with no evidence that any member of the
general public has been hurt, the belief that nuclear power plants are
sufficiently safe grew into a conviction. One must recognize this to
understand why many key steps that could have prevented the accident at Three Mile
Island were not taken. The Commission is convinced that this attitude must
be changed to one that says nuclear power is by its very nature
potentially dangerous, and, therefore, one must continually question
whether the safeguards already in place are sufficient to prevent major
accidents. A comprehensive system is required in which equipment and human
beings are treated with equal importance.
We note a
preoccupation with regulations. It is, of course, the responsibility of
the Nuclear Regulatory Commission to issue regulations to assure the
safety of nuclear power plants. However, we are convinced that regulations
alone cannot assure safety. Indeed, once regulations become as voluminous
and complex as those regulations now in place, they can serve as a
negative factor in nuclear safety. The regulations are so complex that
immense efforts are required by the utility, by its suppliers, and by the
NEC to assure that regulations are complied with. The satisfaction of
regulatory requirements is equated with safety. This Commission believes
that it is an absorbing concern with safety that will bring about safety
-- not just the meeting of narrowly prescribed and complex regulations.
We find a fundamental
fault even with the existing body of regulations. While scientists and
engineers have worried for decades about the safety of nuclear equipment,
we find that the approach to nuclear safety had a major flaw. It was
natural for the regulators and the industry to ask: "What is the worst
kind of equipment failure that can occur?" Some potentially serious
scenarios, such as the break of a huge pipe that carries the water cooling
the nuclear reactor, were studied extensively and diligently, and were
used as a basis for the design of plants. A preoccupation developed with
such large-break accidents as did the attitude that if they could be
controlled, we need not worry about the analysis of "less important"
require extremely fast reaction, which therefore must be automatically
performed by the equipment. Lesser accidents may develop much more slowly
and their control may be dependent on the appropriate actions of human
beings. This was the tragedy of Three Mile Island,
where the equipment failures in the accident were significantly less
dramatic than those that had been thoroughly analyzed, but where the
results confused those who managed the accident. A potentially
insignificant incident grew into the TMI accident, with severe damage to
the reactor. Since such combinations of minor equipment failures are
likely to occur much more often than the huge accidents, they deserve
extensive and thorough study. In addition, they require operators and
supervisors who have a thorough understanding of the functioning of the
plant and who can respond to combinations of small equipment failures.
The most serious
"mindset" is the preoccupation of everyone with the safety of equipment,
resulting in the down-playing of the importance of the human element in
nuclear power generation. We are tempted to say that while an enormous
effort was expended to assure that safety-related equipment functioned as
well as possible, and that there was backup equipment in depth, what the
NRC and the industry have failed to recognize sufficiently is that the
human beings who manage and operate the plants constitute an important