Report Of The President's Commission On
The Accident At Three Mile Island           > TMI-2 > Kemeny

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The Commission

Senior Staff







The Accident




When the decision was made to make nuclear power available for the commercial generation of energy, it was placed into the hands of the existing electric utilities. Nuclear power requires management qualifications and attitudes of a very special character as well as an extensive support system of scientists and engineers. We feel that insufficient attention was paid to this by the General Public Utilities Corporation (GPU).

There is a divided system of decision-making within GPU and its subsidiaries. While the utility has legal responsibility for a wide range of fundamental decisions, from plant design to operator training some utilities have to rely heavily on the expertise of their suppliers and on the Nuclear Regulatory Commission. Our report contains a number of examples where this divided responsibility, in the case of TMI, may have led to less than optimal design and operating practices. For example, we have received contradictory testimony on how the criteria under which the containment building isolates were selected. Similarly, the design of the control room seems to have been a compromise among of the utility, its parent company, the architect-engineer, and the nuclear steam system supplier (with very little attention from the NRC). But the clearest example of the shortcomings of divided responsibility is the area of operator training.

The legal responsibility for training operators and supervisors for safe operation of nuclear power plants rests with the utility. However, Met Ed, the GPU subsidiary which operates TMI, did not have sufficient expertise to carry out this training program without outside help. They, therefore, contracted with Babcock & Wilcox, supplier of the nuclear steam system, for various portions of this training program. While B&W has substantial expertise, they had no responsibility for the quality of the total training program, only for carrying out the contracted portion. And coordination between the training programs of the two companies was extremely loose. For example, the B&W instructors were not aware of the precise operating procedures in effect at the plant.

A key tool in the B&W training is a "simulator," which is a mock control console that can reproduce realistically events that happen within a power plant. The simulator differs in certain significant way from the actual control console. Also, the simulator was not programmed, prior to March 28, to reproduce the conditions that confronted the operators during the accident.

We found that at both companies, those most knowledgeable about th workings of the nuclear power plant have little communication with those responsible for operator training, and therefore, the content of the instructional program does not lead to sufficient understanding of reactor systems.

It is our conclusion that the role that the NRC plays in monitoring operator training contributes little and may actually aggravate the problem. NRC has a limited staff for supervising operator licensing, and many of these do not have actual experience in power plants. Therefore, NRC activities are limited to the administration of fairly routine licensing examinations and the spotchecking of requalification exams and training programs. In evaluating the training of operators to carry out emergency procedures, NRC failed to recognize basic faults in the procedures in existence at TMI. Since the utility has the tendency of equating the passing of an NRC examination with the satisfactory training of operators, NRC may be perpetuating a level of mediocrity.

The way that NRC evaluates the safety of proposed plants during the licensing process has a most unfortunate impact on the way operators are trained. Since during the licensing process applicants for licenses concentrate on the consequences of single failures, there is no attempt in the training program to prepare operators for accidents in which two systems fail independently of each other.

There were significant deficiencies in the management of the TMI-2 plant. Shift foremen were burdened with paper work not relevant to supervision and could not adequately fulfill their supervisory roles. There was no systematic check on the status of the plant and the line-up of valves when shifts changed. Surveillance procedures were not adequately supervised. And there were weaknesses in the program of quality assurance and control.

We agree that the utility that operates a nuclear power plant must be held responsible for the fundamental design and procedures that assure nuclear safety. However, the analysis of this particular accident raises the serious question of whether all electric utilities automatically have the necessary technical expertise and managerial capabilities for administering such a dangerous high-technology plant. We, therefore, recommend the development of higher standards of organization and management that a company must meet before it is granted a license to operate a nuclear power plant.