Nuclear Regulatory Commission

While scientists and engineers have worried for decades about the safety of nuclear equipment, we find that the approach to nuclear safety has 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 accidents large brake accidents require extremely fast action which therefore must be automated 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 the combinations of small equipment failures the most serious mindset is the preoccupation of everyone with the safety equipment resulting in the downplaying 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 safety system.

causes of the accident other investigations have concluded that while equipment failure initiated the event the fundamental cause of the accident was operator error it is pointed out that if the operators or those who supervised them had kept the emergency cooling systems on through the early stages of the accident three mile island would have been limited to a relatively insignificant incident While we agree that this statement is true, we also feel that it does not speak to the fundamental causes of the accident.

Let us consider some of the factors that significantly contributed to the operator confusion.

third the lessons from previous accidents did not result in nuclear instructions being passed on to the operators both points are illustrated in the following case history a senior engineer of the babcock wilcox company suppliers of the nuclear steam system noted in an earlier accident bearing strong similarities to the one at three mile island that the operators had mistakenly turned off the emergency cooling system he pointed out that we were lucky that the circumstances under which this error was committed did not lead to a serious accident and warned that under other circumstances like those that would later exist at three mile island a very serious accident could result He urged, in the strongest terms, that clear instructions be passed on to the operators.

This memorandum was written 13 months before the accident at Three Mile Island, but no new instructions resulted from it.

The Commission's investigation of this incident and other similar incidents within B&W and the NRC indicates that the lack of understanding that led the operators to incorrect action existed both within the nuclear regulatory commission and within the utility and its suppliers we find that there is a lack of closure in the system that is important safety issues are frequently raised and may be studied to some degree of depth but are not carried through to resolution and the lessons learned from these studies do not reach those individuals and agencies that most need to know about them this was true in the b w incident described above it was true about various warnings within the nrc that inappropriate operator actions could result in the case of certain small brake accidents and it was true in several examples of questions raised in connection with licensing procedures that were not followed to their conclusion by the nrc staff There are many other examples mentioned in our report that indicate the lack of attention to the human factor in nuclear safety.

We note only one more, a fourth example.

Holtec says fuel loading is complete and the plant is continuing required testing, inspections, and readiness activities.

The company hopes to return Palisades to service by the end of November, pending completion of the work and all Nuclear Regulatory Commission requirements.

The three counties that oversee Connexus Group say they're making progress toward replacing the agreement that established the agency with some help from the state.

Michigan Labor Department officials spent three hours in St. Joseph Thursday reviewing the county's draft agreement article by article.

The Senate's permitting proposal and a finalized NRC rule target different approval steps, leaving buyers to weigh each project's own delivery constraints.

A finalized Nuclear Regulatory Commission rule and a pending Senate permitting bill both aim to speed approvals for energy projects, but they work on different steps of a reactor's schedule, and neither rewrites the NRC's core safety licensing.

The rule takes effect November 25.

The bill's first procedural vote is reportedly targeted for November 9, six days after the election.

If you read those two books, you'll know more than anyone who's interviewing you.

You'll know more than the people at the nuclear power stations or the NRC because they don't understand radiobiology.

So once you're armed with the facts, then you'll know what you have to do.

No one's ever told me what to do.

So nobody measured what went out of Three Mile Island.

So at best, scientists like me have to calculate based on what we know was measured out in the environment.

The NRC on their website, very shortly after the nuclear disaster at TMI, came out with 10 million curies.

Curies is a measure of radiation.