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Report Index

The Commission

Senior Staff

Transmittal

Preface

Overview

Findings

Recommendations

Views

The Accident

Appendices

PREFACE

WHAT WE DID

The investigation of the Commission was carried out by our able and hard-working staff. We also had the help of a number of consultants and commissioned several studies. It is primarily due to the work of the staff that we accomplished the following.

We examined with great care the sequence of events that occurred during the accident, to determine what happened and why. We have attempted to evaluate the significance of various equipment failures as well as the importance of actions (or failures of actions) on the parts of individuals and organizations.

We analyzed the various radiation releases and came up with the best possible estimates of the health effects of the accident. In addition, we looked more broadly into how well the health and safety of the workers was protected during normal operating conditions, and how well their health and safety and that of the general public would have been protected in the case of a more serious accident.

We conducted an in-depth examination of the role played by the utility and its principal suppliers. We examined possible problems of organization, procedures, and practices that might have contributed to the accident. Since the major cause of the accident was due to inappropriate actions by those who were operating the plant and supervising that operation, we looked very carefully at the training programs that prepare operators and the procedures under which they operate.

As requested by the President, we examined the emergency plans that were in place at the time of the accident. We also probed the responses to the accident by the utility, by state and local governmental agencies in Pennsylvania, and by a variety of federal agencies. We looked for deficiencies in the plans and in their execution in order to be able to make recommendations for improvements for any future accident.  In this process we had in mind how well the response would have worked if the danger to public health had been significantly greater.

We examined the coverage of the accident by the news media. This was a complex process in which we had to separate out whether errors in media accounts were due to ignorance or confusion on the part of the official sources, to the way they communicated this information to the media, or to mistakes committed by the reporters themselves. We examined what sources were most influential on the people who needed immediate information, and how well the public was served by the abundant coverage that was provided. We also attempted to evaluate whether the coverage tended to exaggerate the seriousness of the accident either by selectively using alarming quotes more than reassuring ones, or through purposeful sensationalism.

Finally, we spent a great deal of time on the agency that had a major role in all of the above: the Nuclear Regulatory Commission. The President gave us a very broad charge concerning this agency. We therefore tried to understand its complex structure and how well it functions, its role in licensing and rulemaking, how well it carries out its mission through its inspection and enforcement program, the role it plays in monitoring the training of operators, and its participation in the response to the emergency, including the part it played in providing information to the public.

We took more than 150 formal depositions and interviewed a significantly larger number of individuals. At our public hearings we heard testimony under oath from a wide variety of witnesses. We collecte voluminous material that will fill about 300 feet of shelf-space in a library. All of this material will be placed into the National Archives. The most important information extracted from this in each of the areas will appear in a series of "Staff Reports to the Commission."

Based on all of this information, the Commission arrived at a number of major findings and conclusions. In turn, these findings led the Commission to a series of recommendations responsive to the President's charge.

At the beginning of this volume will be found an overview of our investigation, followed by those findings and recommendations which commanded a significant consensus among the members of the Commission. Each recommendation was approved by a majority of Commissioners.