ML19308C497
| ML19308C497 | |
| Person / Time | |
|---|---|
| Site: | Crane  |
| Issue date: | 07/10/1979 |
| From: | NRC - NRC THREE MILE ISLAND TASK FORCE |
| To: | NRC - NRC THREE MILE ISLAND TASK FORCE |
| Shared Package | |
| ML19308C488 | List: |
| References | |
| TASK-TF, TASK-TMR NUDOCS 8001240655 | |
| Download: ML19308C497 (21) | |
Text
o, Di.4FT Outline of Report / List of Possible Issues To Be Addressed NRC Three Mile Island Special Inquiry i
I. INTRODUCTION Brief discussion of NRC t decision to institute a Special Inquiry under outside, independent supervision. Description of the group t candate, scope,make-up, rathods employed in the study. (List of staff to be supplied as an Appendix).
II.
- 1. HAT HAPPENED?
1.
Narrative This section will be a substantial part (at least on-quarter to one-third) of the report and will contain a detailed integrated, narrative account of the accident from 4 a.m. on March 28 until at least six days later.
The narrative will integrate and codaine 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 intervoven account of how tQ reactor workps ! )
1.2 The utility t response.
t 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 ranagerent, in-
~
cluding make-up and actions of various ad hoc groups formd by ranagemnt, utility t corruni-l cations with NRC, B&W, other utilities, its communications with the state and with the press.
8001240 [ 7 [
3
. 1.3 URC 's' response: this will be a description of what URC personnel actually did.
For the next draft of this outline, we need a nare accurate and corprehensive list of the major contributing NRC conponents; a tentative suggested list of cor.ponents whor: role should be described follows, for comment and critisicm:
1.3.1 First tea:s 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 (Vollner), arriving 3/29.
1.3.3 Designation of Denton as President i delegate, his arrival on 3/30, establishment of on-site NRC command 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 1s liaison and communication with other federal agencies.
NOTE:
We want to isolate and devote our energy to the major NRC individuals and cocponents 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 ray 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.
f
. 1.5 Radiological releases 1.5.1 Uhat kinds of radioactivity does a reactor produce in normal cnd in failure conditions? How are these types of radiocctivity dangerous, and in what doses and circum-stances?
1.5.2 What kinds of radioactivity were probably produced in this accident?
1.5.3 Through what pathways did the radioactivity probably escape, when and in approxinstely what concentrations?
1.5.4 Uhat is the best estinate 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 matters need to be covered in this narrative section, either interwoven in the narrative or possibly set forth separately in conclusory sections.
ITnile in some 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 Uhat were the rajor 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 draft of this outline we need o-more accurate list; a few illustrative itens are suggested below to provoke comment and begin conpilation of such a list:
1.6.1 The 5:30 a.m. conference call on 3/28
, 1.6.2 The a.m. decision on 3/28 to bloudown the system.
1.6.3 The decision in the late afternoon of 3/28 to repressurize How did this decision get made, by whom; who had input?
1.6.4 Decision resulting in 1200 MR release at 6 a.m. on 3/30.
1.6.5 Etc. -- we need to add or subtract as appropriate.
l.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 suar.ary 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 tJRC Commiss-ioners to recommand evacuation, the Chairnan?)
1.8 How bad was the accident and how nJch worse could it have been?
1.8.1 What could or sh.ould have been done to stop or amaliorate 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 arelio-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?
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 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 mioht have happened if:
- 1. 8. 5.1 The reactor had failed to SCRAM?
5-1.8.5.2 RC purps had not been successfully restarted?
1.8.5.3 PORV had not been isolated? (i.e., small break LOCA).
1.8.5.4 Off-site power had been lost?
NOTE: Above list is illustrative only.
In the next draft of this outline, we should specify which alternative sequences we will consider (in-ciuding ameliorative sequences).
1.8.6 How close did TMI-2 core to a more serious core meltdown and greater releases of radioactivity?
1.9 What information was connunicated 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 What 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?).
. II.
2.
Did TMI-2 have any design deficiencies that contributed to the acci dent?
If so, were they (a) unique to this plant, (b) charac-teristic of all similar plants, or (c) characteristic of all or rost 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 comm. ant in our Report.
2.1 Plant systens deficiencies.
Possible examples:
i.cu&ev 2.1.1 Inadequate rimary-cMhmt-inventory 2.1.2 Use of U-bend loop in primary system where steam bubble can arrest natural circulation.
.o 21.3 Use of EMOTS Tn addition to code safety valves' /
(was this in part an attempt to prevent SCRAM and resultant dean-tipa?.)
2.1.4 RHR not designed to operate at system pressure.
2.1.5 Ete:
Are there possible design deficiencies we need to consider in the radwaste system? HPI? Auxiliary feed System? OTSG?)&wt[?
2.2 Cm..and :nd Control deficiencies.
Possible exanples:
4 2.2.1 No reactor trip on turbine trip 2.2.2 No containmant isolation on high radiation alone es n c:ayr cg sfs.
2.2.3 No automatic signal to unblock auxiliary feeddater notorized blok valves.
=2.2
!.. m ui.m 6aciva ueis..! x:'ae-Poscihla rg L.
I l
l 1
l
. t 2.3.1 Inadequate (" missing") instruentation:e.g., No level indicator for reactor vessel.
- 2. 3.2 Instrumentation with ranges not adequate for ab-norral conditions: e.g., thermcouple di splays; various in-plant radiation manitors.
2.:,.3 Inadequate corputer or print-out facilities, especially for real-time reporting in accident situations.
2.4 Sanpling and manitoring deficiencies (TLDs; on-site real-time mnitors) 2.5 Human factors deficiencies. (This category has som overlap r,
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 humn limitations and the possi-bility of huran error in mind. Furthermre, to answer the p
question whether any huran factors deficiencies contributed to the accident, reference will have to be rade as well to the 6., ysis of the contribution of " operator action" discussed in I
anal
/. h h
below.)
f 2.5.1 Poor Control room design.
(
With respect to any " design deficiencies" identified in the above categories, we will have to answer the following questions:
2.6 Was the deficiency, problem or issue rated in arh forum, and l
C 7 should it have been? Specifically, with respect to each m
or conponent identified as having a design deficiencir:
who
'b l
Ep took the lead role in designing it, what kirtl of ana'ysi
,8 dr c, i
3 what was NRC t role, did the matter come up in any licensing hgf/
g review process or appear on a " Unresolved Safety Issue" list, how was it resolved, was the resoltuion proven incorrect?
e' k
A 2.6A Sonewhere here -- possibly either before or after the above section 2.6 -- we will need a descripton of NRC t licensing l
se[
A. M b
b mt J
g A db b OW.
o f.Y p+ p process as it is supposed to work and as it acutally does
, jfj work (or not work); and a description of the I,'RC 's philos-
_ophy of safety.
In short, a description of what the NHL coes and does not do.
y2.7 To what extent are any identified design deficiencies attri-buted to defects in l'RC 's basic philosophy of safetyr tS metted g%y-
+eppWation cf that pMlesophy (e.g., n
.,'> the design basis accident approach, fault tree risk assessment, etc.)
2.8 To what extent are any deficiencies attributible to defects in pk flRC 's licensing and review process? Some of the questions that micht be covered here that are not imm2diately cbvious from the C4 ~
,p above outline (we invite additional suggestions for the next dra
) include:
L 2 8.1 Why was the choice mde not to analyze and design better AU d..
.ked against small loss-of-coolant accidents? Why y a # /[,p '(M**J weren t transients better studied and sirulated?
3 g
p Wasthereke te planning for the effects of an 8
v.
accident involving significant core damage?
{
A y,
- y. (m Qt b" 2.8.3 Why was the presence of noncondensible gas in the primary systen such a surprise to ilRC?
C o
g 8.4 control room design and isntrurentation adoquato?J A
To what extent was human f actors technology used in the g,-
development and design of the control room? How does N. D I'L Mj A
W d.t1 conpare with humn factors standards? With design oncepts used in conparable control rooms (NASA; D0D; M
g p
T hemical industry)?
p 2.8.5 Was adequate attention focused on the probability of pe gV8 human error and the control thereof.Tpecifically,on W
N4 any kinds of humn error that may have played a role in this accident? hfie(a. A f.ediol M 2.9 To what extent are any identified design deficiencies attributable to failings by the vendor (e.g., faulty or fraudulent analysis).
L
. design defji ncies attributible to 2.10 To what extent are any / A MFt:, pM f ailings by the utility 2.11 Can we draw any conclusions cbout the adequacy of f!RC 's
" safety rargin" 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 k(k plants that should have alerted !!RC or the utility to the potential for such an accident?
If so, how was inforration about these events (a
handled, who knew about it, and why wasn i appropriate action taken?
A list of such 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-Besse).
t 3.2 Michelson nemo of 12/77, Pebble Springs questio 3.3 Israel to Novak memo of 1/78 3.4 Cresswell t conplaints; Cresswell remo of 1/79.
3.5 Operating experience: failure rate of PORY t.
3.6 Were there any precursor events or hints of problems in the operating history to TMI-27. What was experience with prior turbine trips? Loss of feedwater?
3.7 Were there recomaendations arising out of previous accident experiences that were not carried out, and that might have helped prevent or ameliorate this accident? (E.g., any lessons from the Brown t 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 t and the industry t failure to N
evaluate prior operating experience (for exanple, possible NRC failure to analyze and act upon LER t) in a canner sufficent to identify safety problems and cure them?
i l
l e
(
l If the NRC'S perforrrance in this area has been deficient, can we identify reasons why is has been?
4.
"er any specific regulatory requirerants, technical specifications, equipment standards, or safety procedares that could or should hcVe been applied to TMI-2 but were not, which might have prevented or amelioratedtheaccident?-(
NOTE:
This section m3 overlap to some extent with Section 2.,
on design de,ff'ciencies, since presurrably identification of a design deficiency might have led to inctitiiting a new J
regulatory requirment. or soecific ofoty nrocedure, to 4.,q[Jd 'g
~
s W
eal with it.
He'. lever, the rain intent of this section is to focus on relatively concrete, detailed specific items:
.Va. 4g g i,f equipment failed, does that show that it should have been
/
p>
required to be safety grade? Would better shif t turn-over t
f
/ procedures have prevented the accident? Would inclusion in the
/
tech specs requirerents for actuation (alarm) upon certain
/
specific events have helped? The section also looks at a set f
/
of possible reasons why such requirements weren "t in place;
/
grandf athering; granting of any exemptions to TMI-2; etc.
/
/
4.l_
Were NRC *s equipment standards adequate? NRC t standards for
( vendor or utility QA Programs?
f 4.1.1 Did the f ailure of equipment contribute to the
/
j accident?
/p N h9 4.1.2 What were NRC S requirements for such equipment?
Should the requirmnts have been higher?
If so, what conclusions can be drawn about why the regulatory process did not work to impose stricter requiremnts.
NOTE:
In section 4.1.2 we will need a discussion of f
j f
l the concept of " safety" as opposed to "non-
/
safety" equipment, and how valid the distinction is.
i
\\
4.1.3 To what extent can equipment failure be traced to defects l
in the quality assurance program of the vendor? How does the NRC oversee or regulate qually assurance? Can I
l we draw any conclusions from equipment failure in this I
accident as to whether such regulations are adequate?
/dse4. we N mVM M
j
<L aus 4 mm,x,
N kW d os. s
& L yp, J ag
'@D dfhb
. 4.2 Were there any procedures _ that were not required by the 4
NRC that might have prevented or ameliorated the accident?
What follows is an illustrative list only; for the next draf t of this outline, tie will need a core accurate, compre-hensive list of any and all procedures we can now identify that might have been deficient and that might warrant attention and/or discussion in our Report:
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-h'f viewed) that might have had an impact on this accident?
g If so, what conclusions can be drawn about NRC t " grand-f athering" approach to safety and about the " ratchet" mechanism NRC uses to implement that approach.
NOTE:
In section 4.3 we will need a factual description of how the ratchet process wor and how decisions whether to retro fit arer iIilly made.
us 4.4 Were there any specific exemptions or amendments granted to O
TMI-2 by NRC that had an impact on the accident?
Were there any new research projects or projected standards p -- -4.5 not yet implemented that might have made a difference?
4.6 Were any specific issues raised and contested in the licensing Qw process that might have made an irpact?
g s
4
4
-TlA-4,7 Should the need for these additional standards or procedures
()nc, 4kbdo~,
have been foreseen?
If so, why weren t they irplemented b#^"'9' A ~
Is this attributible to failings in the NRC licensing before?
and review process? To utility managetent? To.the vendor?
,ga, y.
~
'~
5.
Oid any deficiencies in the status or condition of the plant --
whether or not they constituted " violations" of the license or (pj7/g-NRC regulations -- contribute to the accident and/or releases of radiation and exposures of on-site personnel?
,,,k NOTE:
To sote extent this section will overlap with both 2 and 4.
However, it is the intent of this section to ask whether, even assucnng 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 sirply were.,
1 D
l
. ($#'lf never intended to be ccycred by NRC regulations (v ter w.h ro[]
that in hindsight contributed to the accident.
Of course, the existence of any such conditions might support a conclusion that stricter requirer. ants should have been in place to prevent the conditions, thus putting such conditions into Section 4.rather than this section.
5.1 Physical deficiencies.
The list that follows is not reant 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:
5.1.1 Clogged condensate polisher 5.1.2 Block valves for auxiliary feedaater closed at start of accident.
5.1.3 Leaks in make-up and let-down system.
5.1.4 Clogged filters on make-up systens 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 above).
O
5.3.4 Incdequate raintenance by the utility?
)
5.3.5 Inadequate procedures by the utility?
5.3.6 Poor unufacture or quality control by the mnu-f acturer? (If so, this would rait? questions set forth in 4.1 above).
5.3.7 To what extent do any deficiencies result p
from the utility being permitted to cut W} p safety corners in order to rush the plant
,i
@#pD into " commercial 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 involvemnt (and supervisory managemnt of the operators) play in the accident?
NOTE:
In this section, the operators and their involvement in the accident will be discussed.
This will include operatora 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, insof ar as 4-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,5d 6, to deal as much as possible with all of the questions relating to the operators " role: 1.e., to identify and discuss deficiencies relating to operator qualification, operator eduction, operator training, operator licensing, requirements for control room manning, crew coglements, 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, i
1
. 6.1 Did operator error contribute to the accident?
If so, at what points, and why were those errors made as best we can determine?
6.2 Did the operators have insufficient instrumantation to rake the correct decisions?
6.3 Did the operators have sufficient information but fail to obtain it, or fail to rely on or believe it if they obtained it? Why?
6.4 Are qualifications for operators sufficient?
6.4.1 Describe educational qualifications, licensing gydO procedure and requirments for reactor operators.
Describe type of person who usually serves in an operator position.
6.4.2 Are these reequirmants sufficien Agdetettee-that an operator will have the ability to run a plant safely?
If not, why not?
6.5 Was operator training sufficient?
ph6.5.1 Describe training requirerents and actual training, generally and in the case of these operators.
6.5.2 Was the training adequate to permit.esponse to this emergency situation? Did the operators in fact follow their training?
If so, with what results?
If training was inadequate, what improvements 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 f
kind of accident? What procedures, if any, were followed?
l e
e
. 6.7 Should additional technical expertise be regularly in control rooms? Among questions to be addressed here might be.
1.' hat is the existing philosophy of operator responsi-bility in controlling 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 systems?
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 nay include how long the shift had been together, how nany 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 (family financial, company problens) may have contributed adversely to their conditions, whether any were under unusual stress situations or reacted poorly to stress.
cod was this shift? Mdeb do 6.11 How e
D
f i
. 7.
Uas the planning and response of the NRC for such an accident adequate?
?
7.1 NRC % response plan and planning.
What equip-ment, etc. was actually in place.
What is the NRC 's 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 % 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? /'Sth' %7AN Q,w! Ceu wf 3CJ rd'Mc.
7.6.2 Lack of manpower?
7.6.3 Poor concand at d control, poor ranagerent?
7.6.4 Poor communications?
7.6.5 Inadequate technical resources?
7.6.6 Poor planning?
7.6.7 Poor coordination with utilityP With the state? Other federal agencies?
7.6.8 Poor coordination with State o other federal agencies?
w w
(
1 l
l 7.7 In light of the above, how adequate was !JRC t planning?
7.8
- 1. hat 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 mke sense?
8.
Was the utility t response to the accident adequate?
8.1 Describe the utility t plan. Equipmnt in place, training, etc. Did it met NRC requiremnts, 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?
Evaluate the planning in light of 6 4 Abcet -
8.6 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) Managemnt 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 requiremnts for utility emrgency planning indicated?
(
18_
9.
L*nat was the 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, (2) releases, and (3) the likelihood of evacuation, and actual impleaentation 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 inforration 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 communicated release information to the i
public, and how accurate was it?
1 s What inprovemnts are necessary to it. prove 10.3 manitoring of releases, analysis of data and cormunication of that data in future accidents (planning, roles of various agencies; equip-ment; coordination, and cerrand and control; backup resources for analysis)?
7 Should there have been a conplete evacuation.
10.4 Was the evacuation advisory an unnecessary decisionc? Was the action that was taken decided in a rational way? Was it inplemented effectively? Was planning for it adequate?
How should such decisions be cude and inple-mented? How should they be planned for?
What can be done to inprove the quality and 10.5 timeliness of in#ormation mde available to the public and to decision-making bodies that rust implement evacuation or other public health decisions.
Do the events surrounding the Three Mile Island 11.0 accident raise any questins or suggest any genrali-zations' as to whether our present institutional t
,, i g5 approach to the safe delivery of commrcial 7
b y>' #
nuclear power, in which the public has apparently vsp "6'g~,y#"y-put its faith to date, is indeed adequate?
3 NOTE:
Possible generalizations or questions that g;un ( "
might be drawn from the facts as they emerge This list is illustrative are listed below.
only; it is intended to sticulate thinking about the types of questions we may want to discuss in our Report, even if we cannot resolve them but can only highlight them as issues:
Does the system of placing primary responsi-11.1 bility for safety on the utility, which typically has the least expertise (conpared to the vendor and the NRC), make sense?
i l
L
9 Ubat conclusions can be drawn about the N philosophy of setting design goals and letting the 11.2 vendor develop a design to m2et those goals?
This raises the questions of standardiza 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 3
M g' 7 do any of the fa? Ac. fre #w [d'a tm c
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.
Conpare the NRC to other agencies in 11.3.2 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, cocpetition, mistrust, etc., hanper the Conmission 'h work?
Is the Commission plagued by poor 11.3.4 central managemnt?
Does the Commission have inadequate staff?
11.3.5 Does physical separation of the offices 11.3.6 hinder the work?
(G.k (4. cR d @NI*'*h &y dq1
'^fpGer
?
11.3.7 h t%.r-gg # *$thL P Does the Commission have its priorities wrong?
Does it spend too little time and attention on 11.4 Too nuch on trivia? Does it f ail to safety?
emphasize safety enough?
l l
- W p**
4y w-
-... =
1 t
1 I
I t
III RECO:'."2t:D AT10;JS j
i 4
1 i
i l
I 3
f I
a i;
4 i
J d
f a
l l
l
?
5 a
1 I
4 1
4 i
I i
e s.
i i
1-l t
__