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

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The Accident


Commission Recommendations


1.  To the extent that the industrial institutions we have examined are representative of the nuclear industry, the nuclear industry must dramatically change its attitudes toward safety and regulations. The Commission has recommended that the new regulatory agency prescribe strict standards. At the same time, the Commission recognizes that merely meeting the requirements of a government regulation does not guarantee safety. Therefore, the industry must also set and police its own standards of excellence to ensure the effective management and safe operation of nuclear power plants.

a.  The industry should establish a program that specifies appropriate safety standards including those for management, quality assurance, and operating procedures and practices, and that conducts independent evaluations. The recently created Institute of Nuclear Power Operations, or some similar organization, may be an appropriate vehicle for establishing and implementing this program.

b.  There must be a systematic gathering, review, and analysis of operating experience at all nuclear power plants coupled with an industry-wide international communications network to facilitate the speedy flow of this information to affected parties. If such experiences indicate the need for modifications in design or operation, such changes should be implemented according to realistic deadlines.

2.  Although the Commission considers the responsibility for safety to be with the total organization of the plant, we recommend that each nuclear power plant company have a separate safety group that reports to high-level management.  Its assignment would be to evaluate regularly procedures and general plant operations from a safety perspective; to assess quality assurance programs; and to develop continuing safety programs.

3.  Integration of management responsibility at all levels must be achieved consistently throughout this industry. Although there may not be a single optimal management structure for nuclear power plant operation, there must be a single accountable organization with the requisite expertise to take responsibility for the integrated management of the design, construction, operation, and emergency response functions, and the organizational entities that carry them out. Without such demonstrated competence, a power plant operating company should not qualify to receive an operating license.

a.  These goals may be obtained at the design stage by 1) contracting for a "turn-key" plant in which the vendor or architect-engineer contracts to supply a fully operational plant and supervises all planning, construction, and modification; or 2) assembling expertise capable of integrating the design process. In either case, it is critical that the knowledge and expertise gained during design and construction of the plant be effectively transferred to those responsible for operating the plant.

b.  Clearly defined roles and responsibilities for operating procedures and practices must be established to ensure accountability and smooth communication.

c.  Since, under our recommendations, accountability for operations during an emergency would rest on the licensee, the licensee must prepare clear procedures defining management roles and responsibilities in the event of a crisis.

4.  It is important to attract highly qualified candidates for the positions of senior operator and operator supervisor. Pay scales should be high enough to attract such candidates.

5.  Substantially more attention and care must be devoted to the writing, reviewing, and monitoring of plant procedures.

a.  The wording of procedures must be clear and concise.

b.  The content of procedures must reflect both engineering thinking and operating practicalities.

c.  The format of procedures, particularly those that deal with abnormal conditions and emergencies, must be especially clear, including clear diagnostic instructions for identifying the particular abnormal conditions confronting the operators.

d.  Management of both utilities and suppliers must insist on the early diagnosis and resolution of safety questions that arise in plant operations. They must also establish deadlines, impose sanctions for the failure to observe such deadlines, and make certain that the results of the diagnoses and any proposed procedural changes based on them are disseminated to those who need to know them.

6.  Utility rate-making agencies should recognize that implementation of new safety measures can be inhibited by delay or failure to include the costs of such measures in the utility rate base. The Commission, therefore, recommends that state rate-making agencies give explicit attention to the safety implications of rate-making when they consider costs based on "safety-related" changes.