ML19308C339
| ML19308C339 | |
| Person / Time | |
|---|---|
| Site: | Crane  |
| Issue date: | 07/10/1979 |
| From: | Frampton G NRC - NRC THREE MILE ISLAND TASK FORCE |
| To: | NRC - NRC THREE MILE ISLAND TASK FORCE |
| Shared Package | |
| ML19308C340 | List: |
| References | |
| TASK-TF, TASK-TMR NUDOCS 8001220777 | |
| Download: ML19308C339 (22) | |
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NUCLEAR HEGULAT OR Y cu,AldlSSIOiv
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July 10,1979 hj2 d Y M>%r /II/N
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I E!!3RANDUM FOR:
All Special Inquiry Group Merbers FROM:
George T. Frarpton, Jr., Deputy Directo NRC/TMI Special Inquiry Group h
SLBJECT:
DRAFT OUTLINE OF REPORT Attached is a first draft of an outline of our report, constructed so as to focus attention on the issues and questions that may need to be addressed. This should be regarded as a work in progress, to be revised as we go along.
Some of the subsections in this outline con-tain lists of specific items. These lists are not neant to be definitive; to the contrary, they are illustrative purposes only, so that in succeeding drafts we can begin to supply mare accurate and conprehensive lists of the specific design deficiencies, specific regulatory de-ficiencies, etc. that the Report will have to discuss.
George T. Franpton, Jr., Deputy Director NRC/TMI Special Inquiry Group i
i eoo122 777 g
D%FT o
9 Outline of Report / List of Possible Issues To Be Addressed
!!RC Three Mile Island Special Inquiry i
I. I!!TRODUCTION Brief discussion of !!RC t decision to institute a Special Inquiry under outside, independent supervision.
Description of the group t mndate, scope,mke-up, methods ecployed in the study. (List of staff to be supplied as an Appendix).
II.
DiAT HA?PEliED?
1.
!.'a rra -i ve This se: tion will be a substantial part (at least on-quarter t:. en2-third) of the r; port anc will contain a detailed integrated, narrnive ac: cunt of the accider.t froit 4 a.m. on I Erch 28 until at leist si). cays later.
The narrative will integrate and cotbine the following into a single account:
1.1 The physical sequence in the plant, including operator actions causing these physical events to occur. (This will have to in-clude an intenioven account of how tg reactor works _TS ! )
1.2 The utility t response.
1.2.1 Operator actions (overlap with 1.1 above; this will require clarification of responsibility between Task Groups 1 and 2).
1.2.2 Decisions and actins by utility management, in-cluding trake-up and actions of various ad hoc groups formd by ranagc 99t, utility t coauni-cations with flRC, B&W, other utilities, its corr.unications with the state and with the press.
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o 1.3 NRC % resconse: this will be a description of what NRC personnel actually did.
For the next draf t of this outline, we need a rore accurate cr.d cocprehensive list of the major contributing NRC corponents; a tentative sugcested list of corponents whoccrole should be described follo. s, for comm2nt and critisicm:
1.3.1 First teams of inspectors to arrive on 3/28; how did they perceive their role and authority; what was their expertise; what did they do?
1.3.2 First NRR team (Vollmer), arriving 3/29.
1.3.3 Designation of Denton as President t delegate, his arrival on 3/30, establishment of on-site NRC cortand post.
1.3.4 Region I Incident Response Center 1.3.5 Bethesda Incident Response Center 1.3.6 NRC HQ backup staff 1.3.7 Office of State Prograns 1.3.8 Commi ssioners 1.3.9 NRC t liaison and communication with other federal agencies.
NOTE:
We want to isolate and devote our energy to the major NRC individuals and cotponents that played a role in the accident.
In other words, we need to make some early choices about less-relevant fact-gathering re NRC response that can be given low priority in the inquiry (such as, how nay people in all " played sone role," where they were located, etc.).
1.4 Responseofthestateandotherfederalagencies.fbrthenext draft, we need a list of state offices and agencies, and of other federal agencies, with short descriptions of their re-sponsibilities, capabilities and their roles in this accident.
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s o 1.5 Radiological releeses 1.5.1 Uhat kinds of radioactivity does a reactor produce in norml and in failure conditiens? How are these types of radioactivity dangerous, and in what doses and circum-stances?
1.5.2 khat kinds of radioactivity were probably produced in this accident?
1.5.3 Through what pathways did the radioactivity probably escape, when and in approximtely what concentrations?
1.5.4 khat is the best estimte of the doses and exposures received (a) in the plant, (b) on-site, and (c) off-site as a result?
1.5.5 How were these doses and exposures measured and calcu-lated? What are the bounds on the estimates?
1.5.6 Estimates of danger to health and safety from these doses and exposures. Bounds on the estimates.
A number of specific mtters need to be covered in this narrative section, either intentoven in the narrative or possibly set forth separately in conclusory sections.
khile in som cases these matters are part and parcel of 1.1 through 1.5 (indeed, in some cases they overlap each other), they are separately listed below so that we can identify which matters will be(overed by which Task Groups and individuals within Task Groups:
1.6 khat were the major strategy decisions (or non-decisions) affecting the status of the plant or releases, how were they made, by whom, and on what basis? For the next draf t of this outline we need o.
rore accurate list; a few illustrative items are suggested below to provoke commnt and begin conpilation of such a list:
y 1.6.1 The 5:30 a.m. conference call on 3/28
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1.6.2 The a.m. decision on 3/28 to blowdown the system.
7 1.6.3 The decision in the late afternoon of 3/28 to repressurize 7
How did this decision get made, by whom; who had input?
1.6.4 Decision resulting in 1200 MR rele:se at 6 a.m. on 3/30.
1.6.5 Etc. -- we need to add or subtract as appropriate.
1.7 What were the decisions concerning evacuation? When were they made, by whom, and on what basis? For the next draft of this outline, we need a summary account of major points when evacu-ation was raised, argued for and ordered. (e.g., 3/30 partial evacuation; was there a decision on Sunday by four NRC Commiss-ioners to recommend evacuation, the Chairman?)
1.8 How bad was the accident and how much worse could it have been?
1.8.1 What could or should have been done to stop or ameliorate
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the accident? What was the " anticipated" procedure and why didn 't it work?
1.8.2 What could or should hae been done to stop or anelio-rate the releases? On-site exposures? Why wasn't this done?
1.8.3 How severe was core damage, when did it occur and how?
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When was this known? Generally recognized? When should it have been known?
1.8.4 Was there a hydrogen bubble and when? What danger did it in fact pose?
If the bubble was incorrectly 7
perceived as a significant danger, why did this occur? Where there other scenarios incorrectly perceived to be potentially dangerous?
1.8.5 Alternative sequences:
What might have happened 2:
1.8.5.1 The reactor had failed to SCRAM?
' 1.8.5.2 RC pugs had not been successfully restarted?
f 1.8.5.3 PORY had not been isolated? (i.e., small break
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.LOCA).
1.8.5.4 Off-site powier had been lost?
f NOTE:
Above list is illustrative only.
In the next draft of this outline, we should specify which alternative sequences we will consider (in-cluding anvaliorative sequences).
f 1.8.6 How close did TMI-2 come to a mare serious core mitdown and greater releases of radioactivity?
1.9 khat informtion was communicated to the public (in the form of official statements, press releases, press conferences) by the various parties, and how did this information jibe with the facts.
If inaccurate, why was it inaccurate?
1.10 khat was the "socio-economic" effect on the population living in the area of TMI-27 1.11 Is there any evidence of sabotage? Of bribery 3(i.e., somebody being paid pff to overlook or approve faulty or dangerous equipment?).
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Did TMI-2 have any design deficiencies that contributed to the accident?
If so, were they (a) unique to this plant, (b) charac-
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teristic of all similar plants, or (c) characteristic of all or j
most nuclear power plants?
Possible types of design deficiencies are roughly grouped in five categories below; the examples given in each category are illu-strative only, and for the next draf t of this outline we need to produce a more valid list of possible (or alleged) design defici-encies worthy of our attention and/or comment in our Report.
2.1 Plant systens deficiencies.
Possible examples:
2.1.1 Inadequate primary coolant inventory 2.1.2 Use of U-bend loop in primary system where steam bubble can arrest natural circulation.
2.1.3 Use of EMOV t in addition to code safety valves (was this in part an attempt to prevent SCRAM and resultant down-tine?)
]2.1.4 RHR not designed to operate at system pressure.
2.1.5 Etc:
Are there possible design deficiencies we need to consider in the raddaste system? HPI? Auxiliary feed System? OTSG?
2.2 Command and Control deficiencies.
Possible examples:
7 2.2.1 No reactor trip on turbine trip 2.2.2 No containment isolation on high radiation alone 2.2.3 No automatic signal to unblock auxiliary feedwater motorized blok valves.
2.3 Instrumentation deficiencies.
Possible examples:
. 2.3.1 Inadequate (" missing") instrumantation:e.g., No level indicator for reactor sessel.
2.3.2 Instrununtation with ranges not adequate for ab-normal conditions: e.g., thernoccuple displays; various in-plant radiation nonitors.
2.3.3 Inadequate conputer or print-out facilities, especially for real-tine reporting in accident situations.
2.4 Sanpling and nonitoring deficiencies (TLDs; on-site real-time nonitors) 2.5 Human factors deficiencies. (This category has some overlap with both 2.2 and 2.3 above, insofar as it includes failure to " design" command and control systems or instrumentation or instrumentation displays with human limitations and the possi-bility of human error in mind. Furthermore, to answer the question whether any human factors deficiencies contributed to the accident, reference will have to be made as well to the 6., ysis of the contribution of " operator action" discussed in anal below.)
2.5.1 Poor Control room design.
With respect to any " design deficiencies" identified in the above categoriesc we will have to answer the following questions:
2.6 Was the deficiency, problem or issue rated in any forum, and should it have been? Specifically, with respect to each system or conponent identified as having a design deficiencjr: who took the lead role in designing it, what kini of ana ysis,l46 du.,
what was NRC t role, did the ratter come up in any licensing review process or appear on a " Unresolved Safety Issue" list, how was it resolved, was the resoltuion proven incorrect?
2.6A Sonewhere here -- possibly either before or after the above section 2.6 -- we will need a descripton of NRC t licensing
, process as it is supposed to work and as it acutally does work (or not work); and a description of the I;RC 's philos-ophy of safety.
In short, a description of what the NRC does and does not do.
2.7 To what extent are any identified design deficiencies attri-buted to defects in NRC *s basic philosophy of safety or the m2thod of application of that philosophy (e.g., w-4 the design basis accident approach, fault tree risk assessment, etc.)
2.8 To what extent are any deficiencies attributible to defects in NRC t licensing and review process? Some of the questions'that might be covered here that are not immediately obvious from the above outline (we invite additional suggestions for the next draft) include:
2.8.1 Why was the choice made not to analyze and design better against small loss-of-coolant accidents? Why weren t transients better studied and simulated?
2.8.2 Was there adequate planning for the effects of an accident involving significant core damage?
2.8.3 Why was the presence of noncondensible gas in the
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7 primary system such a surprise to NRC?
2.8.4 Was control room design and isntrumntation adequate?
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To what extent was human f actors technology used in the developmant and design of the control room? How does N.Thl-2 c(!.t1 comare with hunun factors standards? With design concepts used in cogarable control rooms (NASA; D00; chemical industry)?
2.8.5 Was adequate attention focused on the probability of human error and the control thereof?fpecifically,on any kinds of human error that may have played a role in this accident?
2.9 To what extent are any identified design deficiencies attributable to failings by the vendor (e.g., faulty or fraudulent analysis).
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, 2.10 To what extent are any design deficiencies attributible to failings by the utility?
't 2.11 Can we draw any conclusions about the adequacy of NRC t
" safety margin" from any such deficiencies? Why was this accident "not a credible event"?
3.
Were there specific events or experiences at TMI-2 or at other plants that should have alerted NRC or the utility to the potential for such an accident?
If so, how was information about these events handled, who knew about it, and why wasn t appropriate action taken?
A list of sucn events should be supplied for the next draft.
We understand the list might include sone of the following:
3.1 Similar occurrences in 1975 and 1977 (Davis 43 esse).
3.2 Michelson memo of 12/77, Pebble Springs question.
3.3 Israel to Novak memo of 1/78 3.4 Cresswell % conplaints; Cresswell memo of 1/79.
3.5 Operating experience: failure rate of PORV t.
3.6 Were there any precursor events or hints of problems in the operating history to TMI-2?. What was experience with prior turbine trips? Loss of feedwater?
3.7 Were there recommendations arising out of previous accident experiences that were not carried out, and that might have helped prevent or aneliorate this accident? (E.g., any lessons from the Brown i Ferry fire, such as identified lack of lead responsibility for coping with the accident)?
3.8 If precursor events went unheeded, what conclusions can be drawn concerning NRC % and the industry t failure to evaluate prior operating experience (for exanple, possible NRC failure to analyze and act upon LER t) in a nanner sufficent to identify safety problens and cure them?
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. If the NRC 5 performnce in this area has been deficient, can we identify reasons why is has been?
4.
Were any specific regulatory requiremants, technical specifications, equipmant standards, or safety procedures that could or should have been applied to TMI-2 but were not, which might have prevented or ameliorated the accident?
NOTE: This section may overlap to som extent with Section 2.,
on design deficiencies, since presumably identification of a design deficiency might have led to instituting a new regulatory requirment, or specific safety procedure, to deal with it.
However, the main intent of this section is to focus on relatively concrete, detailed specific items:
if equipment failed, does that show. that it should have been required to be safety grade? Would better shif t turn-over procedures have prevented the accident? Would inclusion in the tech specs requirements for actuation (alarm) upon certain specific events have helped? The section also looks at a set of possible reasons why such requirements weren 't in place $
grandf athering; granting of any exemptions to TMI-2; etc.
4.1 Were NRC 's equipmnt standards adequate? NRC t standards for vendor or utility QA Programs?
/ 4.1.1 Did the failure of equipment contribute to the accident?
4.1.2 What were NRC 5 requirements for such equipment?
7 Should the requirments have been higher?
If so, what conclusions can be drawn about why the regulatory process did not work to impose stricter requirements.
NOTE:
In section 4.1.2 we will need a discussion of the concept of " safety" as opposed to "non-safety" equipment, and how valid the distinction is.
4.1.3 To what extent can equipment failure be traced to defects in the quality assurance program of the vendor? How does the NRC oversee or regulate qualiy assurance? Can we draw any conclusions from equipment failure in this accident as to whether such regulations are adequate?
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. 4.2 Uere there any procedures that were not required by the NRC that might have prevented or amalf orated the accident?
What follows.is an illustrative list only; for the next draft of this outline, we will need a nare accurate, conpre-
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hensive list of any and all procedures we can now identify that l
might have been deficient and that might warrant attention and/or discussion in our Report:
1 4.2.1 Shift turn-over procedures 4.2.2 Checklists and sign-off procedures for surveillance of routine maintenance.
4.2.3 Better procedures for responding to certain acci-dent situations.
4.2.4 Health physics procedures or requirments 4.2.5 Etc.?
4.3 Were newer plants subject to requirements (e.g., under the standard safety review plan, adopted after TMI-2 was re-viewed) that might have had an impact on this accident?
If so, what conclusions can be drawn about NRC t " grand-fathering" approach to safety and about the " ratchet" techanism NRC uses to implement that approach.
NOTE:
In section 4.3 we will need a factual description of how the ratchet process works and how decisions whether to retro fit are usually made.
4.4 Were there any specific exemptions or amendments granted to TMI-2 by NRC that had an impact on the accident?
4.5 Were there any new research projects or projected standards
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not yet implemented that might have made a difference?
4.6 Were any specific issues raised and contested in the licensing process that might have made an inpact?
-11A-4.7 Should the need for these additional standards or procedures have been foreseen?
If so, why weren t they impleaented before?
Is this attributible to failings in the NRC licensing and review process? To utility management? To.the vendor?
5.
Did any deficiencies in the status or condition of fhe plant --
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whether or not they constituted " violations" of the license or NRC regulations -- contribute to the accident and/or releases of radiation and exposures of on-site personnel?
NOTE:
To some extent this section will overlap with both 2 and 4.
However, it is the intent of this section to ask whether, even assuming the design was adequate and regulations were adequate, there were conditions in the plant that did not meet the regulatory require-ments, or leaks or other conditions that simply were.1 N
. never intended to be covered by HRC regulations (v WMM 7) that in hindsight contributed to the accident.
Of course, the existence of any such conditions might support a conclusion that stricter requirements should have been in place ;o prevent the conditions, thus putting such conditions into Section 4.rather than this section.
5.1 Physical deficiencies.
The list that follows is not meant to suggest any conclusions, but is illustrative; for the next draft of this Outline, we need a more accurate list of the items that might fall under this category:
7 5.1.1 Clogged condensate polisher y 5.1.2 Block valves for auxiliary feedwater closed at start of accident.
, 5.1.3 Leaks in irake-up and let-down system.
,7 5.1.4 Clogged filters on make-up systems pumps.
5.2 Inadequacies in the health physics program.
Here, too, we need a list of potential matters to be looked into; we understand at this time that the list might include some of the following:
5.2.1 Inadequate procedures and planning 5.2.2 Inadequate training 5.2.3 Etc.?
5.3 Insofar as any deficiencies are identified in the above sections, do these deficiencies indicate:
- 5. 3.1 Violations of regulations?
5.3.2 Inadequate NRC inspection or enforcement 5.3.3 Inadequate NRC standards and requirements? (If so, then this would be an overlap with section 4
- bove).
5.3.4 Inadequate raintenance by the utility?
5.3.5 Inadequate procedures by the utility?
5.3.6 Poor manufacture or quality control by the manu-facturer? (If so, this would raiscquestions set forth in 4.1 above).
5.3.7 To what extent do any deficiencies result from the utility being permitted to cut safety corners in order to rush the plant into "com.ercial operation" by the end of 1978.
Specifically, what tax, rate or other ad-vantages accrued to the utility from going commrcial on the last day of 1978, if any, and what efforts were made to met this dead-line?
6.
What role did operator involvement (and supervisory management of
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the operators) play in the accident?
NOTE:
In this section, the operators and their involvement in the accident will be discussed.
This will include operators training, ' crew selection, operator qualifi-cation, etc, as well as the affects of crew shift, fatique and so on.
The following is a list of questions that may have to be addressed at one or another points during this inquiry.
NOTE: There is potential for overlap between this section and the portion of section 2 that deals with inadequate design for human error and inadequate instrumentation.
There is also potential for overlap between this section and section 4, insofar as & deals with inadequate require-ments (which arguably could include inadequate requirements for training, operator qualification, etc.) and inadequate procedures (which arguably include procedures to guard against operator error).
It is our tentative intention to try to use this section,5ccb 6, to deal as much as possible with all of the questions relating to the operators' role: i.e., to identify and discuss deficiencies relating to operator qualification, operator eduction, operator training, operator licensing, requirements for control room manning, crew complements, how shif t crews are selected and rotated, role of engineers in the control room, the need for more specific operating procedures or manuals in the event of variouf accidents or transients.
We will try to use the design deficiency section (section 2) to talk about inadequate instru-mentation, inadequate control room design, and lack of human factors engineering.
We will see how this division of attention works as we go along.
. 6.1 Did operator error contribute to the accident?
If so,
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at what points, and why were those errors made as best we can determine?
6.2 Did the operators have insufficient instrumentation to make the correct decisions?
.c6.3 Did the operators have sufficient information but fail to obtain it, or fail to rely on or believe it if they obtained it? Why?
L 6.4 Are qualifications for operators sufficient?
6.4.1 Describe educational qualifications, licensing procedure and requirments for reactor operators.
Describe type of person who usually serves in an operator position.
6.4.2 Are these reequirments sufficient to guarantee that an operator will have the ability to run a plant safely?
If not, why not?
6.5 Was operator training sufficient?
6.5.1 Describe training requirements and actual training, generally and in the case of these operators.
6.5.2 Was the training adequate to permit response to this emergency situation? Did the operators in fact follow their training?
If so, with what results?
If training was inadequate, what improvenents or changes might have been made that would have pre-vented or aneliorated the accident.
6.6 Were there adequate rocedures in the control room for this kind of accident? What procedures, if any, were followed?
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. 6.7 Snould additional technical expertise be regularly in control roons? Among questions to be addressed here might be.
What is the existing philosophy of operator responsi-bility in control. ling the plant? Does it place an undue burden on the operators? What role do supervisors play?
Should there have been a highly qualified engineer available on this shif t -- ie., would that have made a difference?
6.8 Did the operators rely insuffficnelty on automatic systens?
6.9 Is there evidence that lack of understanding of the control room or features of the control room played a role in the accident?
(Thius overlaps with portions of section 2.,
above).
6.10 Did the physical and mental conditions of the operators play a role in any identified human error? (Questions to be asked may include how long the shif t had been together, how many days they had worked previously, whether there were enough men on shift, the time of the accident, whether the shift worked together well, whether individuals were physically or mentally fatigued, whether outside influences (f amily financial, conpany problems) may have contributed adversely to their conditions, whether any were under unusual stress situations or reacted poorly to stress.
6.11 How aod was this shift?
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1 7.
Was the planning and response of the NRC for such an accident adequate?
7.1 NRC t response plan and planning.
What equip-ment, etc. was actually in place.
What is the NRC t anticipated role in an accident?
7.2 Summarize briefly the actual response of the NRC which will have been set forth in detail in the narrative in Section 1.
7.3 Was the NRC t plan followed?
7.4 How effective and helpful was the response.
Evaluate the usefulnes of each NRC component listed in Section 1 7.5 How effective was NRC in coordinating with other federal agencies? The state? The utility?
7.6 Identify reasons, if any for lack of more effec-tiveness NRC role.
Suggested possibilities are listed below for feedback:
7.6.1 Inadquate legislature authority?
7.6.2 Lack of manpower?
7.6.3 Poor connand and control, poor nanagement?
7.6.4 Poor connunications?
7.6.5 Inadequate technical resources?
7.6.6 Poor planning?
7.6.7 Poor coordination with utility? With the state? Other federal agencies?
7.6.8 Poor coordination with State or other federal agencies?
. 7.7 In light of the above, how adequate was NRC t planning?
7.8 What should NRC t role be in an accident and how can it plan correctly to fulfill that role?
E.g., can NRC "take over" a plant? Does a SWAT team make sense?
8.
Was the utility t response to the accident adequate?
8.1 Describe the utility t plan.
Equipment in place, training, etc.
Did it meet NRC requirements, if any?
8.2 Summarize actual response from narrative above.
8.3 Was the plan followed?
8.4 How effective was the response?
8.5 What factors prevented the response from being more effective?
8.6 Evaluate the planning in light of fl.4 Aboet -
3 NOTE:
Aspects of the utility t response that might be considered include:
(a)
Initial operating crew (b) Alerting State, NRC, plant (c) Contacting superiors (d) Management by Upper-level Co. personnel (e) Use of technical back-up.
(f) Role in informing NRC, State, other agencies (g) Role in informing public 8.7 Are any new NRC requirements for utility emergency planning indicated?
. 9.
What was tiie response of other federal agencies and the state?
9.1 Describe state authority.
9.2 Describe the roles anticipated for other federal agencies.
9.3 Describe analytically and evaluate the roles the state and other federal agencies actually played.
(sare overlap on evacuation with Section 1 and 10).
9.4 Describe the White House role.
9.5 Analyze the question of whether NRC made the best use of these other resources.
9.6 What ought the role of the state and other federal agencies be in an accident situation, and how should the NRC utilize them and coordinate with them?
- 10. The public was not adequately informed as to (1) the dangers and potential dangers involved in the accident, J
(2) releases, and (3) the likelihood of evacuation, and actual implementation of evacuation.
NOTE: There will be sone overlap between this section and sections 1 and 9.
10.1 Was this due to conscious decisions or rather to negligence, poor coordination, or lack of reliable information on the part of those communicating with the public?
10.2 With respect to the monitoring of releases, whose responsibility was this, was there adequate planning, who did the monitoring, who was supposed to collate the information, how was this actually done, who comaanicated release information to the public, and how accurate was it?
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10.3 What inprovercants are necessary to improve monitoring of releases, analysis of data and communication of that data in future accidents (planning, roles of various acancies; equip-ment; coordination, and command and control; backup resources for analysis)?
7 10.4 Should there have been a conplete evacuation.
Was the evacuation advisory an unnecessary decisions? Was the action that was taken decided in a rational way? Was it implemented effectively? Was planning for it adequate?
How should such decisions be made and imple-mented? How should they be planned for?
10.5 What can be done to improve the quality and timeliness of information made available to the public and to decision-making bodies that must implement evacuation or other public health decisions.
11.0 Do the events surrounding the Three Mile Island accident raise any questins or suggest any genrali-
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zations as to whether our present institutional approach to the safe delivery of concercial nuclear power, in which the public has apparently put its faith to date, is indeed adequate?
NOTE:
Possible generalizations or questions that might be drawn from the facts as they emerge are listed below. This list is illustrative only; it is intended to stimulate thinking about the types of questions we nay want to discuss in our Report, even if we cannot resolve them but can only highlight them as issues:
11.1 Does the system of placing primary responsi-bility for safety on the utility, which typically has the least expertise (compared to the vendor and the NRC), make sense?
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. Uhat conclusions can be drawn about the NRC philosophy of setting design goals and letting the 11.2 vendor develop a design to meet those goals?
This raises the questions of standardization and of greater regulatory involvemnt in design.
Are there institutional aspects of the NRC it-self that tend to inhibit its fullfilment of 11.3 For example, its statutory responsibilities?
ctors itsted below play a 5
M do any of the fa? Ac< Dre Mb fedvs significant role The history of NRC 'S creation from the AEC, and the AEC 'S traditional promotional 11.3.1 role.
The Coimmission form of regulation.
11.3.2 Compare the NRC to other agencies in which regulation of economic behavior is done by Commission (ICC, FTC, CAB,
SEC) but the protection of the public health and safety is committed to single-Administrator groups (FDA, EPA, FAA, MHSA, OSHA).
Does the autonony of the various offices within the NRC, including possible lack 11.3.3 of coordination, conpetition, mistrust, etc., hamper the Comission t work?
Is the Commission plagued by poor 11.3.4 central management?
Does the Commission have inadequate staff?
11.3.5 Does physical separation of the offices 11.3.6 hinder the work?
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11.3.7
\\s t%. r-ef Does the Commission have its priorities wrong?
Does it spend too little time and attention on 11.4 safety? Too nuch on trivia? Does it fail to emphasize safety enough?
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III RECOMtENDATIONS