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Overview: CAUSES OF THE ACCIDENT Other investigations have concluded that, while equipment failures 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 operator confusion. First of all, it is our conclusion that the training of TMI operators was greatly deficient. While training may have been adequate for the operation of a plant under normal circumstances, insufficient attention was paid to possible serious accidents. And the depth of understanding, even of senior reactor operators, left them unprepared to deal with something as confusing as the circumstances in which they found themselves. Second, we found that the specific operating procedures, which were applicable to this accident, are at least very confusing and could be read in such a way as to lead the operators to take the incorrect actions they did. Third, the lessons from previous accidents did not result in new, clear 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 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 NRC that inappropriate operator actions could result in the case of certain small-break 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. The control room, through which the operation of the TMI-2 plant is carried out, is lacking in many ways. The control panel is huge, with hundreds of alarms, and there are some key indicators placed in locations where the operators cannot see them. There is little evidence of the impact of modern information technology within the control room. In spite of this, this control room might be adequate for the normal operation of nuclear power plants. However, it is seriously deficient under accident conditions. During the first few minutes of the accident, more than 100 alarms went off, and there was no system for suppressing the unimportant signals so that operators could concentrate on the significant alarms. Information was not presented in a clear and sufficiently understandable form; for example, although the pressure and temperature within the reactor coolant system were shown, there was no direct indication that the combination of pressure and temperature meant that the cooling water was turning into steam. Overall, little attention had been paid to the interaction between human beings and machines under the rapidly changing and confusing circumstances of an accident. Perhaps these design failures were due to a concentration on the large-break accidents -- which do not allow time for significant operator action -- and the design ignored the needs of operators during a slowly developing small-break (TMI-type) accident. While some of us may favor a complete modernization of control rooms, we are all agreed that a relatively few and not very expensive improvements in the control room could have significantly facilitated the management of the accident. In conclusion, while the major factor that turned this incident into a serious accident was inappropriate operator action, many factors contributed to the action of the operators, such as deficiencies in their training, lack of clarity in their operating procedures, failure of organizations to learn the proper lessons from previous incidents, and deficiencies in the design of the control room. These shortcomings are attributable to the utility, to suppliers of equipment, and to the federal commission that regulates nuclear power. Therefore -- whether or not operator error "explains" this particular case -- given all the above deficiencies, we are convinced that an accident like Three Mile Island was eventually inevitable.
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