ML20206Q780
| ML20206Q780 | |
| Person / Time | |
|---|---|
| Site: | Shoreham File:Long Island Lighting Company icon.png |
| Issue date: | 12/18/1986 |
| From: | Perrow C LONG ISLAND LIGHTING CO., YALE UNIV., NEW HAVEN, CT |
| To: | |
| References | |
| CON-#287-3150 86-533-01-OL, 86-533-1-OL, OL-5, NUDOCS 8704220035 | |
| Download: ML20206Q780 (190) | |
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TRAXSCRIPT ee c_RC u'T OF PRCCEEDIX 8 -
20 A8 55 ORG%AL oN1TED STATES Or AMER 1cA orrice ce sscettaav 00CKEilNG A SERVICf.
BRANCH NUCLEAR REGULATORY COMMISSION BEFORE THE ATOMIC SAFETY AND LICENSING BOARD
- - - - - - - - - - - - - - - - - - -x In the Matter of: :
- Docket No. 50-322-OL-5 LONG ISLAND LIGHTING COMPANY : (EP Exercise)
(Shoreham Nuclear Power Station, : (ASLBP No. 86-533-01-OL)
Unit 1) :
_ _ _ _ _ _ _ _ _ _ _x 0 DEPOSITION OF CHARLES PERROW Washington, D. C.
Thursday, December 18, 1986
! ACE-FEDERAL REPORTERS, INC.
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Washington, D.C. 20001 b~ (202) 347-3700 l
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UNITED STATES OF AMERICA 2 NUCLEAR ~ REGULATORY COMMISSION BEFORE THE ATOMIC SAFETY AND LICENSING EOARD
'3
-_._______________._x 4 :
In the Matter of: :
+ -
- Docket-No. 50-322-OL-5 5l LONG ISLAND LIGHTING COMPANY : (EP Exercise) 6 (Shoreham. Nuclear Power Station, : (ASLBP No. 86-533-01-OL) -
l . Unit-1) :
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8i DEPOSITION OF CHARLES PERROW 9
^* "9 " *
- 10 Thursday, December 18, 1986 11 , '
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(} 12 Deposition of CHARLES PERROW, called for examination-pursuant to notice of deposition, at the law offices of Kirkpatrick and Lockhart, 1800 M Street, N.W., Suite 900, 14
! at 9:15 a.m. before WENDY S. COX, a Notary Public within l
.15 .I' and for the District of Columbia, when were present on 16 ,, behalf of the respective parties: i
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17 ' , KARLA J. LETSCHE, ESQ.
SUSAN CASEY, ESQ.
IR Kirkpatrick & Lockhart l
South Lobby, Ninth Floor 19 ) 1800 M Street, N.W. ,
- Washington, D. C. 20036-5891
- On behalf of Suffolk County.
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APPEARANCES (Continued): '
l 23 I l JESSINE A. MONAGHAN, ESQ.
THOMAS E. KNAUER, ESQ.
3l Hunton & Williams 707 East Main Street 4l !
P. O. Box 1535 Richmond, Virginia 23212 On behalf of Long Island 5I Lighting Company.
6'j RICHARD J. ZAHNLEUTER, ESQ.
7 Deputy Speci~al Counsel to the Governor Executive Chamber 8l Capitol, Room 229 Albany, New York 12224 9l i On behalf of the State of New York.
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- - - C O N T-E N T S 2 WITNESS EXAMINATION Charles Perrow 3
by Mx.-Monaghan 4_
4 5h E X H I~B I T S'
.ll 6 l! PERROW DEPOSITION NUMBER IDENTIFIED 7 -l Exhibit-1 18 i
Exhibit 2 62 8
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2' Whereupon,.
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CHARLES PERROW
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.4 was called as a witness and, having first been duly _. sworn,
- 5. .was examined.and testified as follows:
6 EXAMINATION
-7. BY MS. MONAGHAN:
8 Q Dr. Perrow, my name is Jessine Monaghan.
I am-9 with the law firm of Hunton & Williams. We represent Long 10 Island Lighting Company in this proceeding before the 11 licensing board of the Nuclear Regulatory Commission. I am
' :O 12 '. going to be asking you a number of questions this morning.
13 If at any time you need to have a question' clarified or.if 14 you would like to expand upon an answer you have already l' 15 given during the course of this deposition, please-let me 16 know.
17 A Okay.
18 Q For the benefit of the court reporter, when your 19 answer to a question is yes, please so state that it's yes.
20 Do not nod your head, because it's difficult for the cou t i reporter to record that as a response.
21 1
22 Would you state your full name and address for the O ,
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2 A Yes. Charles Bryce, B-r-y-c-e, Perrow, 3 P-e-r-r-o-w, 44 Denison, D-e-n-i-s-o-n, Drive, Guilford, 4 G-u-i-1-f-o-r-d, Connecticut 06437.
SL 'Q Dr. Perrow, are you represented at this deposition 6 by counsel?
7 A Yes.
8 Q Who is-that counsel?
9 A Karla Letsche.
10 Q Did you bring with you today any documents?
11 A- No.
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\~' Did you meet with Ms. Letsche or anyone else in 12 Q 13 preparation for your deposition?
14 A Yes.
15 Q When did you meet with Ms. Letsche?
16 A I met yesterday with Ms. Letsche.
17 Q Did you meet with anyone else other than 18 Ms. Letsche?
19 MS. LETSCHE: One of our associates was also 20 present, Ms. Casey.
21 THE WITNESS: Oh, yes, Susan.
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1 .BY MS. MONAGHAN:
4 2- Q. ~Where did that'meetingsoccur?
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- 3 A In this room..
4 Q For-how-long did you-meet with Ms. LetscheLand
~5 Ms. Casey?~
6 A I~would say from about 1:00 to 5:00.
7 Q Was that the first time.that you met in order to 8 prepare-for your deposition?
9 A ~No.
p 10 Q When was the previous occasion and who was 11 present?
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12 A Oh, I am sorry. Let me correct that. In 13 preparation for the deposition,-that was'the only time we i 14 met, yes.
1 1 15 Q Did you meet with Ms. Letsche or someone else at i
- 16. some other time in connection with this case?
i 17 A Yes.
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- 18. Q When was that?
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. 19' A Two meetings. One was, I believe, early in 20 December or late in November at my office at Yale; and the 21 second meeting was about a week ago at the 1900 M Street 22 offices of the law firm.
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{'s l 1 Q That-law firm being Kirkpatrick.&'Lockhart?-
'2 A Yes.
- 3- _-Q~ Who was present in1the_ meeting that' occurred in 4 either early, December or late' November?
5 A -Karla_Letsche and. Mike -- what isfhis name?
6 MS. LETSCHE: Miller.
7 .THE WITNESS: Miller.
8 BY'MS. MONAGHAN:
.9 Q Who was present at the meeting that you had:a week 10 ago at 1900 M Street? ~
11 MS. LETSCHE: Let me stop you. I will state that 1(
12 present at that meeting was-Lee Coldwell'and Mr.-Miller of my.
13 office. I was present there, and another gentleman who has 14 not yet been identified as a witness. But we intend-to 15 identify him shortly.
16 BY MS. MONAGHAN:
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- 17 Q Dr. Perrow, who was present at the meeting ~a week
", 18 ago at 1900 M Street?
19 MS. LETSCHE: That's what I just said.
1 20 MS. MONAGHAN: I think the witness can answer the 21 question.
- 22 MS. LETSCHE
- I think not. I have provided the
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':t As-1 answer'to-yourl question, i 2- MS. MONAGHAN: What is the basis on which=you are 3 instructing th'e witness.nSt to' answer.the question,;
11 Ms.~Letsche?
.5 MS. LETSCHE: You already.have it before'you. You 6 may ask.the witness if his answer would be the same as mine:
7 if'you would like.
8 BY MS. MONAGHAN:
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9 Q My question stands, Dr. Perrow. Who was present
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10 at the meeting at 1900 M Street last week?
11 A I would give the same answer as Ms.'Letsche gave.
o' 12 Q Do you know the name of the other person other 13 than Mr. Coldwell, Mr. Miller'and Ms. Letsche who was at the 14 meeting?
15 A I think it's --
4
-16 MS. LETSCHE: You may answer whether or not you 17 know the gentleman's name.
l' 18 THE WITNESS: I have forgotten, honestly.
19 MS. LETSCHE: That takes care of that. c 20 BY MS. MONAGHAN:
i 21 Q So you don't know his name. You don't recall what 4
22 his name is?
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,_j 1 A No, I have a hard time with names.
2 Q Was it in fact a gentleman who was present at that 3 meeting or was it a lady?
4 A I don't -- should I answer that?
5 MS. LETSCHE: Jessine, I have told you it's a 6 gentleman.
7 THE WITNESS: I forgot you said that.
8 MS. LETSCHE: You will learn his name at the 9 appropriate time, after the contracting procedures have been 10 completed. I think you should move on.
11 BY MS. MONAGHAN:
("
12 Q Dr. Perrow, during the meeting that was held 13 yesterday to prepare you for your deposition, were you shown 14 any documents?
15 A Yes.
16 Q Do you recall what those documents were?
17 A Yes.
18 Q What were the documents?
19 A The contentions of the governments of Suffolk 20 county and the state. Is it proper to refer to them as the 21 governments? Some of the documents--
22 MS. LETSCHE: Yes, that's fine, o
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1 BY MS. MONAGHAN:
2 Q You are using the term " governments" to refer to 3 the intervenors in this proceeding, Suffolk County, the State 4 of New York and the town of South Hampton; is that correct?
5 A Fine.
6 Q Were you shown any other documents other than the t
7 contentions?
8 A No.
9 Q At the meeting that occurred in early December or 10 late November, were you shown any documents or provided any 11 documents?
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12 A No.
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13 Q What about the meeting that occurred a week ago at 14 1900 M Street? Were you shown or previded any documents at 15 that meeting?
16 MS. LETSCHE: I am going to instruct the witness 17 not to answer that question in that it gets into attorney 18 l work product information. You can certainly inquire of 19 Dr. Perrow as to what documents you have seen or reviewed in 20 connection with the formation of opinions or beliefs with 21 respect to his testimony in this proceeding, but I am not 22 going to permit him to answer concerning meetings that he had n
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1 with counsel.
2 MS. MONAGHAN: Ms. Letsche, you have permitted him 3 to answer with respect to the other two meetings that he has 4 had with counsel. If you are instructing the witness not to 5 answer, could I have the basis for that instruction.
6 MS. LETSCHE: I just stated it.
7 MS. MONAGHAN: Is your basis that it's a work 8 product objection?
9 MS. LETSCHE: Yes, that's right.
10 MS. MONAGHAN: Is it an attorney / client privilege 11 objection?
'- I stated my basis. It's attorney 12 MS. LETSCHE:
13 work product.
14 MS. MONAGHAN: Thank you, Ms. Letsche.
15 BY MS, MONAGHAN:
16 Q Dr. Perrow, did you have any telephone 17 conversations with anyone in preparation for the deposition 18 testimony you are giving today, that you recall?
19 A Today? No.
20 Q When you used the term "today" -- did you have any 21 telephone conversations prior to today in order to discuss 22 the testimony that you were going to give?
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1 A' Are you referring to the testimony or the' 2 deposition?-
3 Q The deposition testimony that you gave.
4 A Okay. No . .
5 _Q Did you'have any telephone conversations with~
6 anyone concerning_the testimony that you'are going to give at-
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7 the' hearing of this proceeding?-
8 A -I would say no.
9 Q Dr.-Perrow, we have established that you have seen 10 'the contentions that are at issue-in this proceeding. Have 11 you reviewed any.other documents or materials in preparation O 12. for your deposition?
13- A Yes.
14 Q What would those documents be?
15' A I have reviewed some of the OPIPs, the portions of 16 the FEMA reports on the exercise, and I believe that's all.
'17 No, that's not the case. I have also reviewed 18 some prior documents from prior litigation in connection with 19 this case.
20 MS. LETSCHE: Off the record a secon 21 (Discussion off the record.)
22 MS. MONAGHAN: Back on the record.
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- l/m 1- BY.MS. MONAGHAN:
2 Q Dr. Perrow, do you recall which documents you- <c i
3 reviewed from the prior' litigation?.
e 4. A~ Not that clearly. I read them.just to get~a 5= feeling for the case and' background.
6 -Q. Do you recall'whether they were in the nature of.
7 testimony that was given?
8 A .Yes. Yes, I am sorry. It was. testimony.
9 Q .Did you review the opinion that the' licensing' 10 board wrote:in the prior litigation? t I' 11 A The opinionuof-the licensing board?
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\J 12 .Q The decision in the case.in the. prior litigation?.
13 A I am not sure.
14 -Q But you do recall that you did review some 15 testimony from the prior litigation?
16 A Yes. I now recall there was testimony from i
17 Dr. Mileti and Dr. Erickson. There were other names, but I 18 was not familiar with them, so I don't recall them, i
19 Q You said that you have -- I am sorry, had you I
20 completed your answer?
21 I A Yes.
22 Q You also stated that you reviewed some portions of l ,
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v 1 the FEMA report. Do you recall what portions of the FEMA 2 report you reviewed?
3 A I read the introductory or conclusion part, and I 4 examined the charts'or figures -- you know, EOC-1 -- of 5 those. I went through those briefly.
6 Q Were those the charts that appeared at the back of 7 the FEMA report?
8 A Yes. I also read some other parts within it, but 9 I mainly just skimmed it.
10 Q Did you skim the main part of the report or some 11 other parts?
12 MS. LETSCHE: Objection.
13 THP WITNESS: It would be hard for me to say.
14 BY MS. MONAGHAN:
15 Q Do you recall the charts in detail that appeared 16 at the end of the FEMA report?
17 A I don't know what you mean by " charts."
18 Q You said that you reviewed some charts or figures 19 at the end of the FEMA report.
20 A Yes.
21 Q Do you recall whether that was a detailed review 22 that you did or what?
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l' A Oh,)I misunderstood your question. lio , it ' was n ' t' 2 a' detailed -- I have done no detailed review of the FEMA.
3' = report.-
2 4 14 S . MONAGHAN: Off the record.
5- (Discussion off.the record.)
6 MS. MONAGHAN: Back on the' record.
7~ BY MS. MONAGHAN:.
8 Q' Dr. Perrow, you also indicated that you have 9 reviewed'some-of the OPIPs. Do you recall which of the OPIPs 10 you reviewed? If not by number, then by what they dealt 1
11 with.-
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12- A Yes. I certainly couldn't recall them by number.
13 I looked at some that dealt with training, I think, and, oh, 14 who was to fill which position. I don't really recall much i
15 more. I was just getting a feeling for what these.were.
16 Q When you reviewed the contentions, did you review l 17 all of the contentions?
, 18 A No.
19 Q Do you recall which of the contentions you 20 reviewed?
i 21 A I am not sure I will get the numbers right, but I 22 think the ones I expected to testify on.
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v' 1 lQ Do you have~any idea which numbers those are on 2 which you are expected to testify?
3 A 13, 16, 22, 41 and 50, I believe, but I may be 4 wrong there. I didn't commit them to memory.
5 Q Dr. Perrow, when did you learn that you were going.
6 to be a witness in this case?
7 A Early in December.
8 Q When did you review the various documents that you 9 have reviewed?
10 A Between that time and now.
11 Q Do you know about how much time you spent t 1 12 reviewing the documents that you have reviewed?
13 A Several hours.
14 Q On the order of three, four or five hours?
15 A Oh, I think it would be more than that.
16 Considerably more, yes.
17 Q Can you give me an approximate number, with the 18 understanding that it's an approximation?
19 A Eight.
20 Q Other than the documents that you have listed for 21 me -- and those are the contentions, some of the OPIPs, 22 portions of the FEMA report, and documents from the prior Po ACE-FEDERAL REPORTERS, INC.
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2 correct characterization of what you said -- please correct 3 me if I am wrong -- have you reviewed any other documents in 4 preparation for your deposition or in preparation of the 5 testimony you expect to give in the hearing?
I 6 A Yes. I would include in those hours, which --
-7 eight hours is probably a large amount of time -- I would 8 include in there I looked at some appendices to these 9 documents that dealt with news reports, newspaper articles, 10 regarding the Shoreham nuclear plant.
11 Q Do you recall at all what the newspaper articles k'/ ~ 12 concerned?
13 A Yes. They concerned the ability of the management 14 of Shoreham to run a plant.
15 Q Did you review any newspaper articles that dealt 16 with a poll taken by Stephen Cole?
17 A No, I did not.
18 Q Dr. Perrow, I am going to show you a copy of your 19 resume, which has been provided by counsel--
20 MS. LETSCHE: May I have a copy.
21 BY MS. MONAGHAN:
22 0 -- and ask that it be marked as Perrow Deposition i
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1 Exhibit Number 1.
2 (Perrow Exhibit 1 identified.)
3 BY MS. MONAGHAN:
4 Q Would you please review this resume. .W hen you 5 have had an opportunity to review it, tell me whether it.
6 accurately describes your education and employment 7 background.
8 A Yes, it does.
9 Q Are there any statements in the resume that are 10 not correct as of the present time?
11 A I hope not.
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~# 12 Q Are there any recent developments that are not 13 included in your resume. I note the date on the top of it is 14 June of '86.
15 A Yes. That's a mistake. That date should have 16 been changed, because there is an October entry. So it 17 should have been changed to 10/86 so it is up-to-date.
18 Q Dr. Perrow, have you ever testified before in 19 court or in any other administrative proceeding?
20 A Yes.
21 Q Which proceedings have you testified in?
22 A The ones that are identified in my resume. Oh,
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1 no, I am sorry -- yes, testimony for Friends of the Earth at 2- the Indian Point restart hearings.
3 Q What was the nature of the testimony that you gave 4 at those hearings?
5 A Discuss the potential for accidents at nuclear 6 power plants in general and Indian Point in particular.
7 Q Did any of the testimony you gave concern training 8 in any respect?
9 A Yes.
10 Q How did.it deal with the training?
11 A I believe it argued that training for some kind of A
U 12 of events was very difficult.
13 Q Were those events which would occur within the 14 power plant itself?
15 A Yes.
16 Q Have you ever testified concerning training for 17 emergency planning in the context of an off-site response 18 organization?
19 A No.
20 Q Have you ever testified concerning emergency 21 planning for an off-site response organization?
22 A No.
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1 Q Did your testimony at the Indian Point restart
- 2. hearings concerning the behavior of persona in emergency?
3- MS. LETSCHE: I object to the question. I think 4 that's very vague and generalized. Maybe you could be more 5 specific.
6 BY MS. MONAGHAN:
7 Q Dr. Perrow, do you understand the question?
8 A No. That's pretty general behavior.
9 Q Did your testimony at the Indian Point restart 10 proceeding deal with the behavior of plant personnel at a 11 nuclear power plant in the event of an emergency?
O 12 A Behavior of personnel? I suppose it did. I am 13 not sure that I understand what you mean. It dealt with 14 emergencies, and emergencies involve people and how people 15 behave. So I guess I did.
16 Q Did your testimony deal with the ways in which 17 people react to an emergency situation?
18 MS. LETGCHE: Ms. Monaghan, do you have a copy of 19 Dr. Perrow's testimony? I note this was given back in '82.
20 I am not sure he is fully familiar with it. If you intend to 21 ask a lot of questions, perhaps you could give him a copy to 22 refer to.
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1 MS. MONAGHAN: I don't have the copy with me.
2 BY MS. MONAGHAN:
3 Q Dr. Perrow, are you having difficulty remembering 4 what you testified to in 1982?
5 A Yes, on such a specific question -- or such a 6 vague question as that one.
7 Q What do you recall about the testimony that you 8 gave at the Indian Point restart hearing?
9 A Do you want a summary of that testimony?
10 Q Yes, please.
11 A All right. The summary is that in systems which b,_
12 are highly complex and tightly coupled, there is the 13 possibility for the multiple interaction of errors which were 14 not anticipated by design engineers and not comprehensible to 15 operating personnel; and such interaction of errors can-16 defeat the safety systems and cause disruption of plant 17 operations.
18 Q Dr. Perrow, what do you mean by the term " highly 19 complex and tightly-coupled systems."
20 A A complex system is a system which has many parts 21 that interact in other than a linear manner; and 22 tightly-coupled involves several criteria. One is very o
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%l 1 little time available; that is, time-dependent processes, few 2 substitutions available of personnel or equipment or 3 supplies. Only one way to keep the system running; that is,-
4 it can't be run backwards or sideways or stopped. Is.that 5 sufficient? That's roughly the notion of tight coupling.
6 Q If that gives a' full explanation of your meaning 7 of the term " tight-coupled," that will'be sufficient.
8 A A full explanation would require my reciting for 9 you several -- a chapter of a book. So I don't think that we 10 can do that.
11 Q I think you are right. I think this is sufficient
/ )
12 for the purposes of this deposition. When you used the term 13 " multiple interaction of errors," what did you mean?
14 A That errors interact with one another.
15 Q Can you give me an example of that?
16 A At Three Mile Island a failure of the condensate 17 system, water system, allowed some moisture to get into an 18 instrument air line, which sent a false signal to the turbine 19 that there was no steam supply for the turbine. Therefore, 20 the turbine shut down, and when the turbine shuts down, the 21 feed water pumps shut down. But then it's necessary that the 22 auxiliary feed water pumps start up. And the second error (2) t ACE-FEDERAL REPORTERS, INC.
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'l ~ now--is that.those pumps werezclosed;.they'had been left 2- closed'by. mistake.
3 So the interact' ion of_ errors'is the error in the
'4 'first case, that the valve leaking during the maintenance 5' work'th'at sent water into the line. That created an 6 unexpected error; that'is, a false' signal to the turbine,
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7- which then interacted with the fact-that the emergency feed 8 water pumps were closed. . And that's just two of four major 9 errors in that accident.
10 Q Getting back to the testimony that you gave in the 11 Indian Point' restart. hearing, did any of your testimony
( 12 concerning the multiple. interaction of errors in highly
- 13. complex and tightly coupled systems involve the behavior of
.14 persons in an off-site emergency response organization?
j 15 A Not that I recall.
16 Q So your testimony was specific to what occurred at 17 the plant and, personnel at the power plant itself; is that i
18 correct?
I 19 A To-the best of my knowledge.
b 20 Q Have you testified in any other proceedings or 21 actions other than the testimony you provided for Friends of 22 the Earth at the Indian Point restart hearings?
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%..J 1 A No.
2 Q Dr. Perrow, are the professional associations 3 described in your resume an accurate description of your 4 professional affiliation?
5 A Are you referring to honors and menberships?
6 Q Yes.
7 A Yes.
8 Q Does your resume also indicate whether you have 9 held any offices in those particular professional 10 associations?
11 A Yes, it does.
( i
\- 12 And it's correct, to the best of your knowledge?
Q 13 A Yes. .
14 Q Otherthanthearticlesllistedunder"booksand 15 published monographs," articles,and books listed on your' 16 resume, have you authored or co-authored any other books, 17 papers or reports, other than the ones that are listed on 18 your resume? i 19 A What do you mean by " reports"?
20 Q Just using the term " report" in a generic sense to 21 be sure that we encompass all of the wrikings which you may 22 have authored.
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1 A Not as we.normally accept that term in my 2 profession. This is the fullest of my. bibliography.
3 Q How is that term " authored" usually defined in 4 your profession?
5 A. Well, I wouldn't list a report that I made for the 6 -- I am=trying to think of some of the reports, internal 7 university affairs, report on undergraduate education or ,
8, 'something like that.
9- Q Would this list include.any work that you.may have 10 done as a consultant, for' example, with the Institute of
- 11. Public Service in New York City?
n 12 A No.
13 O Would it --
14 A It does include work that I did for the Office of.
15 Naval Research.-
.16 Q That's your paper entitled "The organizational
- 17. Context and Human Factors"?
'18 A Yes.
I 19 Q Does this paper -- does your resume include any 20 writings that you would have done in connection with your 21 affiliation with Battelle Institute, as a panel member of a 22 group studying the optimal organization structure for nuclear O
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1 power plants?
2 A Yes. The book " Normal Accidents" reflects some of p
3' .that work.
-4 'Q. Dr.-Perrow, what are the terms:of your' engagement 5 as a.witn'ess'in this proceeding?
6~ MS. LETSCHE: I object to.the question as being.-
7 vague. I don't know what that means.
8 BY MS.--MONAGHAN:
9 Q .Do you understand the question, Dr. Perrow?
5 10 A- No.
11 Q Did you enter into a contract with the-Kirkpatrick:
~
12' & Lockhart firm in connection with the testimony you are-13 supposed to provide in this proceeding?
14 A No.
15 :Q What were you hired to do in this. proceeding?
- 16 A What was I hired to do?
i
. 17 Q In this proceeding.
18 A I assume it's to give testimony.
L 19 Q Are you to testify as an expert witness in this 20 proceeding?
21 A I believe so.
22 Q What is the subject matter on which you expect to
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1 testify?
2 MS. LETSCHE: It's already been asked and 3 answered.
4 BY MS. MONAGHAN:
5 Q You may answer the question, Dr. Perrow.
6 A The subject -- well, I am going to testify on 7 certain contentions of the law firm.
8 Q What is the subject of'those contentions?
9 A The exercise conducted by LERO, L-E-R-0, capital 10 letters.
11 Q Can you be a little more specific about the U, 12 opinions which you expect to render in this proceeding beyond 13 that you are going to testify about the exercise.
14 MS. LETSCHE: Jessine, that's a much too vague and 15 general question. If you want to ask him about opinions on 16 particular contentions, that's fine. We are not going to let 17 you ask him to make a speech to testify generally about what 18 he is going to testify on from start to finish. That's too 19 broad a question.
20 BY MS. MONAGHAN:
21 Q Dr. Perrow, do you understand the question?
22 MS. LETSCHE: I am not going to let him answer.
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1 If you want to ask about specific contentions, that is fine.
2_ MS. MONAGHAN: What is your basis?
3 MS. LETSCHE: That's too general a question. A 4 deposition is not a forum for you to ask a witness to make a 5 three-hour speech. If you want to ask him particular 6 opinions or about what his beliefs are concerning particular 7 contentions, that would be fine. That would be a sufficient 8 way to proceed, and I will let him.
9 MS. MONAGHAN: You are instructing the witness not 10 to answer the question because you believe it is too vague 11 and inappropriate and not let him answer the question.
(~) 12 MS. LETSCHE: I have stated my objection. He has 13 stated his testimony. You know it's about specific 14 contentions. If you want to ask h'im what the specific 15 contentions, are that's fine. I am objecting to a question 16 as to would you be more specific as to what your testimony is 17 going to be.
18 BY MS. MONAGHAN:
19 Q Dr. Perrow, do you expect to render opinions as an 20 expert in providing testimony in this proceeding?
21 MS. LETSCHE: That's calling for a legal 22 conclusion by the witness. He said he believes he is going g
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1 to be testifying as'an expert witness.
2 -BY MS. MONAGHAN:
3 Q Dr. Perrow, what subject matters do you consider 4 yourself to be an expert'on?
5 MS. LETSCHE: Again, I object. That is calling 6 for a legal conclusion. Dr. Perrow, you can describe for 7 Ms. Monaghan your areas of academic study, if that's what she 8 wishes to know.
9 BY MS. MONAGHAN:
10 Q That is not the question that I have put before 11 you, Dr. Perrow. You have indicated to me that you
,es.
'~ 12 understand you are going to testify as an expert in this 13 proceeding, that your expertise is being drawn on to provide.
14 testimony; is that correct?
15 A Yes.
16 Q What specific areas of your expertise are being 17 drawn on to Travide testimony in this proceeding?
18 MS. LETSCHE: If you know, you may answer that.
19 THE WITNESS: I would refer to a statement in my 20 l curriculum vitae on my teaching interests: " Complex 21 organizations, industrial society, technology and social i 22 change, social movements, research design, sociological
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1 theory . "' I think all of those would be involved to some 2 extent.
3 BY MS. MONAGHAN:
4' Q All of them would be involved?
5- A To some extent, yes.
6 Q Would you explain for me what you mean by the term 7 " complex organizations" and how that relates to the testimony 8 that you are going to be providing.
9 MS. LETSCHE: That's a compound question. Why 10 don't you do them one at a time. Tell her what complex 11 organizations are.
/ i 12 THE WITNESS: Complex organizations are amazingly 13 hard to define because there's a great deal of disagreement 14 about them, about the definition in the field. For example, 15 it's hard to find the boundaries of an organization, what is 16 inside an organization and what is outside an organization.
17 It's rather hard to decide whether a family is an 18 organization or not, whether or not it's a complex 19 organization, because you need some criteria for the various 20 levels of hierarchy within the organization. Some people say 21 that an organization is only complex if it has three levels 22 of hierarchy: It has a head, which may be a person or a n
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, -cox 31-f.). l' committee, and reporting toJthem is another layer of people,
,2' and then reporting to those is another layer ofLpeople. .That 3 would be a three-tier organization. For some people that'
'4 become's a complex organization. Other people define them in-
~
5 terms of the variety of activities.that the organization-6 ~does. So-if you"have multiple activities which might be- -
7- reflected.by different divisions or departmentu, then it 8 becomes complex.
9 So the answer to the question is'not simple. I
~
10 could go'on if you wish.
11 BY MS. MONAGHAN:
~
12- Q You said that there is disagreement 1in the field-13 of sociology about the definition of~ complex' organizations, 14 and you gave me two possible examples of'the definition. One '
15 l's something where you look at the tiering of the t
16 organization; three-tiered indicates a complex' organization.
17 Is that the definition that you would apply yourself to:a i
18 complex organization?
19 A Not necessarily.
I 20- Q Is that one of the criteria to which you would I
21 look in defining a complex organization?
22 A It's one, but it's not necessarily essential.
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1 Q You also indicated that one of the definitions of 2 a complex organization is that it is one which conducts a 3 variety of activities. Is that a criteria which you would 4 apply to define a complex organization?
5 A Depending on how you defined the activities, yes.
6 But there would be disagreement about a variety of 7 activities.
8 Q So there would be disagreement among other 9 sociologists about what would constitute the sufficient 10 variety of' activities to make up a complex organization; is 11 that a correct restatement?
There wouldn't be that much. You asked 12 A Not much.
13 me, I believe, about the definition. There is disagreement 14 'about the definition. There is very little disagreement as 15 to whether this phenomenon is or is not a complex 16 organization. Those are two different things.
17 Q What phenomenon are you referring to?
18 A Well, this collection of individuals, whether that 19 is or is not a complex organization.
20 Q- Which collection of individuals are you referring 21 to?
22 A Whichever one you wish to ask about. If you ask CZ)
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j 1 me about a collection of individuals and you say is that a 2 complex organization, we-would get pretty general.
3 Q Do you consider the LERO organization a complex 4 organization?
5 A Very definitely.
6 Q Are there certain problems affiliated with complex 7 organizations?
8 A Absolutely.
9 Q- What are those problems?
10 A I am sorry, I have written a book called " Complex 11 Organizations" which has roughly 350 pages dealing with those
12 problems. I am not sure what you want me to answer.
13 Q In connection with the LERO organization, what 14 would you term the problems. that -- strike that.
15 You have defined the LERO organization as a 16 complex organization. Which of the problems that you 17 consider are typical of complex organizations are present 18 with the LERO organization?
19 A I am not sure what I would say on that, because as 20 I indicated in my testimony, I haven't examined that 21 gI organization that carefully. I would be very hesitant to 22 prejudge it.
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11 Q' So:at.this time, based.on the study that you have 2- done of.t'he LERO organization to date,cyou cannot assign or 3' determine which of the problems lthat.are typical'of complex 4 organizations are present with a LERO organization; is.that 5 correct?
6 A Not definitively.
7 Q 'Do you have some~ general ideas, or would'it"be-too 8 speculative to say at this point?
.9 A .It would be speculative, but I have no objection 10- to sharing with you. I find it to be a very hierarchical 11 organization, an organization 1that apparently was incapable
~
12 of' responding to unexpected events. -It was alsofan 13 organization that was unable.to; mobilize personnel-quickly..
14 It was also an organization.that -- whose training'did not 15 apparently prepare people ~very~well. 'Those kinds of things.
16- Q What do you mean when you used the term 17 " industrial society" as one.of your areas of teaching l
18 interests? -
[ 19 MS. LETSCHE: Are you referring to something in
- 20 particular on Dr. Perrow's resume?
21 THE WITNESS: Yes, " industrial society," bottom of j_
~22 page 3. The U.S. is an industrial society.
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1 BY MS. MONAGHAN:
2 Q Do you beliere that you will be drawing on your 3 studies.in the discipline of industrial society in connection 4- with providing testimony in this proceeding?
5 A I would think so.
6 Q How would those studies be applied to the LERO
~7 organization?
8 MS. LETSCHS: I object. Assumes a fact not in 9 evidence. I object to the form.
10 BY MS. MONAGHAN:
11 Q You may answer the question, Dr. Perrow. It's an 12 objection as to form.
13 A Oh, as to form.
14- MS. LETSCHE: If you can answer it, go right 15 ahead.
16 THE WITNESS: Could you repeat it again? I didn't 17 understand it.
18 BY MS. MONAGHAN:
19 Q Sure. You have indicated that one of your 20 [ teaching interests is industrial society.
I 21 A Yes.
22 Q I believe that you have defined that term.
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1 A Yes.
2 Q You have indicated that you believe that you would 3 apply that to the LERO organization in'the testimony that you 4 are going to be --
5 MS. LETSCHE: No, he has not said that.
6 BY MS. MONAGHAN:
7 Q Dr. Perrow, is that your testimony, that you 8 intend to apply the concepts of industrial society to the 9 LERO organization?
10 A Oh, no, I didn't say that.
11 Q Please correct my mistake then.
(,\
12 MS. LETSCHE: I think your prior question, 13 Ms. Monaghan, was if he intended or assumed that his general 14 experier.ce and studies in that field, among the others listed 15 in his teaching interests, would be brought to bear in 16 preparing his testimony. That was his affirmative answer.
17 THE WITNESS: Perhaps I can explain it this way.
18 It would make no sense to study complex organizations without 19 knowing something about an industrial society, because there 20 are very few of them in a nonindustrial society. It would 21 make no sense to study complex organizations without knowing 22 something about technology, technological change, because, as v
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j 1 our society is constituted, complex-organizations are very 2 connected to. technology and technological change. That would 3 be my way. As far as specifically relating the LERO 4 organization to industrial society I don't anticipate that.
5 BY MS. MONAGHAN:
6 Q Do you anticipate -- strike that.
7 Your use of your studies in industrial society and 8 technology and social change will be used to put the LERO 9 organization in a context as opposed to applied to it 10 directly?
11 A Yes.
\ /
'~' Would you define for me what you mean by the term 12 Q 13 " social movements," which is listed under your teaching 14 interests?
15 A Yes, I will. But I think I probably misspoke 16 there. I don't.think that's going to be relevant to this 17 this activity. Social movements there refers to studies I 18 have done in the area of the civil rights organization, 19 women's liberation, welfare rights organization, the right to 20 abortion, 19th-century movements in labor, alcohol, 21 temperance unions and things like that.
l 22 I think I was -- I misspoke when I tied that to 1
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'- 2- 'MS. LETSCHE: -I am not sure yo'u7did tie.,it'Lto.--
that. Don't be so..quicksto chastise yourself.
4' BY MS. MONAGHAN:
' 5. Q I th' ink you did include all of your teaching 6 ~ interests',.so that includes what you relied on'specifically.
7 .A Yes.
8 Q What about the term "research design." What do
'9 you mean by:the use of that term?
10- A .How you design research.
11- Q Sometimes the obvious is not so-obvious..
^ (3 12- A. Okay. Yes, you are right.
j l13 " Q- How do you expect to.use your expertise in t
14 -research design in' connection with the testimony you are
+
15 going-to-_be providing-in this proceeding?
16' A I expect to do research on the exercise, and-it'L 17 important to know some of the principles of research design
! 18 in order to be that effective.
19 Q Do you have any idea at the present time how you
-20 will structure this research that you are going-to do on the 21 exercise?
22 A No.
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1 Q Do you know what documents you might want to look 2 at to develop your research design?
3 A Oh, I certainly will.look at the OPIPs and the 4 FEMA' valuation and the contentions, and there may be.many 5 more, but I am not sure what documents are out there. I 6 really don't know. I have just come aboard.
7 Q Are there certain research theories that are 8 typically applied to the evaluation of performance, human 9 performance?
10 MS. LETSCHE: I object to the form of that 11 question. If Dr. Perrow can answer it -- I didn't understand 12 it but maybe he does.
13 THE WITNESS: There is a tradition called 14 evaluation research, a field, let's say, within social 15 sciences, that -- I don't know that it's relevant to this 16 case. I don't think so.
17 BY MS. MONAGHAN:
18 Q Do you have any preliminary ideas on the research 19 techniques that you might be using in connection with any 20 research you would do on the exercise?
21 A Yes. I would read everything I could about the 22 behavior during the exercise and analyze it.
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1 Q What criteria would you use to analyze it?
2 A Whether the organization behaved as it is expected 3 to by the nuclear regulatory agency regulations and by.its 4 own professed' goals.
5 Q Would you look at the LERO -- would you use the 6 plan and procedures to define what the goals of the LERO 7 organization are?
8 A I would certainly examine the plan and 9 procedures. I think that is one that I have: looked at now 10 that you have reminded me. I think I have seen'something on 11 their plans and procedures, yes.
12 I would look at those. I don't think that-13 necessarily is evidence of the goals.
14 . Q- Where would you look to find evidence of the 15 goals?
16 A Rather hard. I would look at behavior, for one 17 thing.
18 Q Dr. Perrow, were you at the FEMA exercise?
19 A No.
20 , Q Have you spoken with anyone who was present at the i
21 FEMA exercise?
22 A No, unless it were counsel. I am not sure that U<s ACE-FEDERAL REPORTERS, INC.
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I counsel was there. I forget.
2 Q Have you discussed with anyone their observations 3 of the FEMA exercise?
4 A No.
5 Q How would you go about then looking at the 6 behavior of the LERO organization.if you were not present at-7 'the exercise?
8 A I would look at the FEMA report, which reports on 9 the behavior of the organization.
10 0 Do you expect that you would look at documents 11 that bere generated by the LERO. players during the course of
('#' 12 the e::ercise?
13 A I might.
14 Q Do you expect that you would look at critique 15 forms that were filled out by FEMA observers?
16 A I might.
17 MS. LETSCHE: If he could get them he might.
18 ,
THE WITNESS: I was going to anend that and say I i
19 would love to.
20 BY MS. MONAGHAN:
21 Q In looking at the critique forms that were used by 22 the FEMA observers, would you look at the objectives that G
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1 werefon those critique forms as indicative of the. goals 'f o
- 2 ' the. organization?.
3 MS. LETSCHE: Let me just make sure. I' don't' know-4- if Dr. Perrow -- I don't know if there is a foundation for .
S- that, some of the terms that you used in.that question. You 6 might want to back up.
7 -BY MS, MONAGHAN:
- 8. Q Dr. Perrow, are you having difficulty-with the f
9 nature of the; question?
A Yes, because I haven't seen those reports. I 11 don't know what they say.
- 9 12 Q ~ Let's go back. Dr. Perrow, you have reviewed the 13 FEMA exercise assessment; is that correct?
14 A Yes.
15 Q Did you note in the FEMA exercise assessments that t
16 there were objectives' listed in that assessment?
17 A Yes.
1 18 Q Let me note for you-that those objectives were 19 listed on the critique forms used by the FEMA evaluators.
20 A Yes.
21 Q Would you consider those objectives to be i
22 indicative of the goals of the LERO organization?
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1 A No.
2 Q Would you consider those objectives to be 3 indicative of what FEMA thought it was testing the day of the 4 exercise?
3 A I am not sure.
6 Q Why are you unsure? Is there some specific thing 7 that makes you unsure?
8 A I don't have the information on the FEMA 9 personnel, and I haven't seen those forms you are talking 10 about. I am very reluctant to talk about a formula. You 11 have represented as to having the objectives timely -- or all
('~'I 12 radials were at the top and then filled out. I would 13 hesitate to call that a goal.
14 Q In evaluating the exercise, you indicated that you 15 would read everything you could about the behavior of the 16 persons and you would apply certain criteria to your 17 evaluation. I think the criteria that we have just been 18 discussing is whether the organization behaved as it was 19 expected to do by the NRC and by the goals of the 20 organization itself. Is that a correct restatement of what 21 you have said?
22 A Yes.
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v' 1 Q Is there any other criteria that you would look to 2 in evaluating the exercise?,
3 A There might be.
4 Q Do-you have any idea of what the criterion or 5 criteria might be at this time?
6 A No. It's very hard to even say what I know. I 7 guess I can't at this time. It's a vague kind of thing. Let 8 me put it this way. The basis upon which LERO can be judged 9 is not limited, I don't think, necessarily, by those two 10 criterion. There may be other criteria that I would want to 11 suggest. But I don't know those criteria yet. I really
( )
don't know that much about it, all the things that have gone 12 13 on. I haven't even examined all of the contentions.
14 Q Will you be relying on any of your published works 15 for the opinions you expect to give in this proceeding?
16 A Yes.
17 Q Which ones specifically do you think at this time 18 you will be relying on?
19 MS. LETSCHE: Off the record.
20 MS. MONAGHAN: Back on the record.
21 BY MS. MONAGHAN:
22 Q Dr. Perrow, before the break I asked you which of
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J 1 your published works you intend to rely on for the testimony 2 you are going to give in this proceeding.
Could you indicate 3- which'of them you intend to rely on?
4 A It's hard to say. Most of my writing deals with 5 organizations and different aspects of organizations; and I 6 don't know which ones I would exclude from any of these. So 7 it's really hard to say.
8 Q Why is it difficult to say which ones you would 9- exclude?
10 A Because my work is spread over many books, and 11 many of them are irrelevant. It would be -- we don't have
('s
() 12 compartmentalized, or I don't have a compartmentalized --
13 there is a rough difference there between social movement 14 literature that I have produced, which is a minor part of 15 that, and the organization. That, I am pretty sure. But the 16 organization stuff is maybe 20 articles and three, four 17 books.
18 Q Well, let's look at your resume. Do you think you 19 are going to be able to be relying on the first publication 20 there, which is listed study on a non-segregated 21 hospitalization of alcoholic patients in a general hospital?
22 ! A I don't know. I might.
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1 Q What concepts in that paper do you think you would 2 be relying on?
3 A I don't know. .That was done 20 years ago, 30 4 years ago -- couldn't be.
5 Q Not quite 30 years ago.
6 A No, I was looking at the first one, " retirement 7 . programs. " Okay. Which one were you referring to, number 8 4? Yes.
9 Q Let's look at your books first, okay, which are on 10 the prior page.
11 A That one. All right. That is a long time ago.- I 12 doubt it.
13 Q What about the second one listed there, 14 " Comparative Study of Juvenile Correctional Institutions"?
4 15 A Possibly.
16 Q What is the general thesis of that. book?
i 17 A My goodness. For routine -- you need different 18 organizational structures for different tasks, and depends on 19 -- how do you define the juvenile delinquents? You define 20 them one way, structure the organization one way. You define 21 them another way, you structure the organization another 22 way, n
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1 -Q Do you see any link on an organizational basis 2' between juvenile correctional institutions and the LERO 3 organizations such that this book would apply?
4 .JL They are both organizations. That certainly is a 5 link.
6 Q Other than the fact that they are both 7 organizations, is there more direct link between juvenile 8 correctional institutions and LERO organizations such that 9 one would apply your work " Organization for a Comparative 10 Study of Juvenile Correctional Institutions" to the LERO 11 study, apply the concepts of it?
12 A Apply the concepts, yes. But you wouldn't apply 13 -- you wouldn't say that the West Virginia Reform School for 14 Boys is similar to LERO. But the concepts, yes.
15 Q The concepts being organizational concepts; is 16 that correct?
17 A Yes.
L 18 Q What about your work " Organizational Analysis: A 19 Sociological View"; are you going to rely on that in giving 20 your testimony?
I 21 1 A Probably.
l 22 l Q What about " Complex organizations: A Critical l
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,x-1 Essay"?
2 A Yes.
3 Q How about "The Radical Attack on Business"?
4 A Not likely.
5 Q Not likely?
6 A No.
7 Q What about " Normal Accidents: Living with 8 High-risk Technologies"?
9 A Quite possibly.
10 Q You have also written a number of research.
11 articles or chapters in a book which are listed in your fh 12 resume.
13 A Yes.
14 Q Do you believe that you will be relying on the 15 article "Are Retirement Adjustment Programs Necessary" that 16 appears in the Harvard Business Review?
17 A No.
18 Q What about "Gemeinschaft and Gesellschaft: A 19 Critical Analysis of the Use of Polar Typology"?
20 A Very unlikely.
21 Q What about "Research in a Home Care Program"?
22 A Unlikely.
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1 Q What about " Nonsegregated Hospital" --
2 A Unlikely.
3 Q How about " Organizational Prestige"?
4 A Possible.
-5 Q What about " Reality Shock: A New Organization 6 Confronts the Custody-Treatment Dilemma"?
7 A Possible.
8 Q What about the next one, " Goals and Authority 9 Structures"?
10 A Possible.
11 Q What about " Sociological Perspective and Political 12 Pluralism"?
13 A No.
14 Q What about."The Reluctant Organization and the 15 Aggressive Environment"?
16 A Possible.
.17 Q What about " Hospitals, Technology, Goals and 18 Structure"?
19 A Quite possible.
20 Q What about " Reality Adjustment: A Young 21 Institution Settles for Humane Care"?
22 A Possible.
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1 Q How about " Technology and Organizational 2 Structure"?
3 A Possible.
4 Q What about --
5 A Could I save us some time?
6 Q Certainly.
7 A I will go through and give you the numbers--
8 Q Okay.
9 A -- of the ones that are possible or quite 10 possible.
11 Q Fine.
rx
\ )
12 A Would that be all right?
13 Q That would be fine.
14 A 13, 14, 16, 18, 23, 24, 26, 28, 32, 33, 34, 35, 15 and 39; and I would add that I may, in fact, draw upon any of 16 the others, but I can't guarantee.
17 Q. But at this time you think that the ones that you 18 listed are the likely candidates?
19 A Yes, yes. Will you read them?
20 Q Undoubtedly.
21 A Good. That's all we live for, is to have our 22 stuff read.
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1 29296.0 cox 51 1 Q Dr. Perrow, are you familiar with NUREG-0654; do 2 you know what that is?
3 A No.
4 Q Are you familiar with FEMA Guidance Memorandum 17?
5 A I may be, but I don't know it by that number.
6 Q FEMA Guidance Memorandum 17 concerns the 7 development of a FEMA grade exercise.
8 A No.
9 Q Are you at all familiar with any of the materials 10 used in the LILCO training program?
~
11 A No.
12 Q I think you have already established that you 13 haven't reviewed any of the LERO player documents that were 14 used during any of the exercise; is that right?
15 A No.
16 Q What are your criticisms of the LERO 17 organization's behavior on the day of the exercise. Did you 18 hear the question?
! l I
19 l A Yes.
20 l - MS. LETSCHE: I object to that question, Jessine.
4 21 l That's much too broad. If you want to, as I said, go through 22 and ask for Dr. Perrow's opinions concerning the contentions s ;
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cox 's 52 1 upon which h,e is going to testify, that will be fine. But-2 asking him to' sit here and list criticisms in a vacuum 3 concerning what! happened over a nine- or 10-hour period on 4 February 13 is just not_the proper way to proceed in a 5 deposition. If you want to ask him specific questions, I am 6 sure he will be glad to answer them for you.
3-7 THE WITNESS: g i would agree. I was surprised by 8 your question. Yes, I Would agree with that.
9 BY MS. MONAGHAN:
10 Q Let's put this aside for a while.- Dr. Perrow, 11 what is a normal accident?
?3 3
'~ # A normal accident sometimes, or better referred to 12 A 13 as a-system accident -- and I described it earlier as the 14 multiple interaction of failures that produces an accident 15 which is unanticipated by managers and designers and not 16 always, but generally incomprehensible to the operators.
17 Q What do you consider a high-risk technology that 18 would be the kind in which a normal accident can be expected 19 to occur?
20 A Nuclear power plants, nuclear weapons, chemical 21 plants, air transport, marine transport, recombinant DNA 22 technology are some of those.
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-1 Q- Is:it your opinion'that a normal-accident is as .
L 2 .' 'lik y to occur at one nuclear power plant as another?'
- 3' :A No.
4 Q Are they more likely to occur at one nuclear power
. -S- . plant than another?
'6 A Yes. If you mean'that plants vary by their 1
l7 vulnerability to a normal accident; is that what'you are-8 asking?
9- Q Is that what you.mean when you .ay you don't think-
-10 they are all_the same, that.they vary with the vulnerability.-
.. 11 to accidents?
Q .
.12 A Yes.
+
-13 Q What is.that variance in. vulnerability based on?
14 MS. LETSCHE: Let me pose an objection to the 15 relevance of this, Jessine. I have permitted you to go for-16 over an hour now on all sorts of. things, some of which.'have 17 been relevant but an awful lot haven't. I fail to see the .
18 relevance of talking about vulnerability of plants to 19 accidents with respect to the exercise litigation and the 20 contentions to which Dr. Perrow has been identified as a-21 witness.
22 As you know, there is another deposition scheduled n
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29296.0 cox 54 i i 1 at 2:30 this afternoon, so there is a limited amount of time 2 in which to depose Dr. Perrow. I would suggest that you get t , on with obtaining some relevant information from him. I 4
4 -wouldn't waste'any time talking about something that hasn't.
5 I will permit him to answer, though, if you want to continue 6 on this line.
7 BY MS. MONAGHAN:
.8 Q Dr. Perrow, I am trying to understand the concept
-9 of normal accidents. You have written a number of articles.
10 and a book entitled "The Normal Accident" in which you set 11 forth your thesis about what constitutes a normal accident,
/;}
12 that they can be expected to occur with high-risk 13 technologies. You have also indicated that you may rely on 14 some of those books and articles in connection with the 15 testimony which you are going to give in this proceeding;'is 16 that correct?
.17 A Yes.
18 Q I am trying to understand what you mean by your 19 thesis on these books. Now, you have indicated that there 20 can be a variance among nuclear power plants which would make 21 them more or less susceptible to a normal accident. What are i
22 the criteria that you would use to define what the variance n
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1 would be?
2 A Well, I could go into that. I don't think - I 3 don't see the relevance to the LERO organization and the FEMA 4 organization, but it's your time. Certainly the training, 5 equipment, competence of the manager, honesty of the 6 personnel; the ability of the nuclear regulatory agency to 7 supervise the design, inspect the construction, supervise the 8 training of the operators, to test the operators -- generally 9 the kinds of things that make organizations well-run or 10 poorly run has an impact. And I think you will appreciate 11 the number of failures that you are likely to have, failures
_ {
# 12 of design, of procedures, of operators, of machinery, of 13 supplies, or the entirety. So, plants vary in the extent to 14 which they are vulnerable to a system accident.
15 0 Is there any way in which one could design a plant 16 and train personnel to man that plant which would completely 17 obviate the possibility of a normal accident, in your 18 opinion?
19 A There might be. I haven't seen any, but there 20 l might be.
21 Q So, in your opinion, the nuclear power plants with 22 which you are familiar, none of them are immune from a normal nv ACE-FEDERAL REPORTERS, INC.
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L' V 1 accident; is-that correct?
-2 A Yes.
~3 Q You are familiar with the Indian Point' plant,-
4 based;on your testimony-for Friends of the Earth.in..the 5 restart proceeding; are those the ones with;which you are 6 ' familiar?
7 A .Yes. '
8 Q Other than the Indian Point plant and the TMI 9 plant which were discussed earlier,.are you familiar with any 10 other nuclearLpower plants in the, United States?-
..- '11
- A~ What do you mean by " familiar."
'" ) 12 Q You said the power plants with which you are
~ 13 . familiar, you do not believe that any'one of them is immune 14 from a normal accident. I am i..st trying.to determine 15 ,whether you have universal familiarity or whether it's 16 limited.to only a few power plants.
17 -A Okay. Fair enough. I know a fair bit about half 18 a dozen plants and a little bit about most of the. plants; so 19 I would phrase it in that sense. I have not examined all 90:
20 -- whatever it is, operating plants. I am not. familiar with 21 all of the plants. I am familiar with Indian Point, TMI -- I 22 am talking about the operating ones now. Considering that
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( 'I 1 Shoreham is not operating, Rancho Seco, Diablo Canyon, 2 Davis-Besse, FERMI 2, FERMI 1, which is no longer operating, 3 the Surry plant and a few others. Varying degrees of 4 familiarity.
5 Q But those are the plants in which you would 6 include in your statement of ones which you are familiar, 7 none is immune from a normal accident?
8 A Yes.
9 Q As you define the term " normal accident"?
10 A Yes.
11 Q Now, does the concepts of normal accident take
' )
~' 12 into account the existence of off-site emergency plans?
13 A No. That's why I am surprised at this line of 14 questioning.
15 Q- You intend to apply the normal accident theory to 16 -the testimony "then" that you are going to give in this 17 proceeding?
18 MS. LETSCHE: I will object. I am not sure your 19 question is clear in terms of what you mean by "the normal 20 accident theory." I am not sure that such a theory exists.
21 BY MS. MONAGHAN:
22 f Q Dr. Perrow, you have written extensively on what
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i 29296.0 cox 58 7.m, E i LJ 1 you have termed the " normal accident." I'believe it's a 2 theory that you have developed; is that correct?
3 A Yes.
4 Q Do you understand --~ define for me what you would 5 term a normal accident theory.
6 A I am sorry, say that again.
7 Q Can you define for me what you --
8 A Normal accident theory, I did, about twice.
9 Q We are talking about the same thing?
10 A Yes.
11 Q High-risk technologies which --
'~)'
i 12 MS. LETSCHE: It's on the record. Don't try to 13 state it again.
14 MS. MONAGHAN: Ms. Letsche, I would appreciate it 15 if you would cease from interrupting my questions.
16 MS. LETSCHE: I am sorry, I apologize for-17 interrupting. I was trying to speed up a little bit.
i 18 MS. MONAGHAN: I understand we have a time 19 limitation of 2:30 during Dr. Perrow's deposition, and I will 20 try to adhere; but I believe during the realm of discovery I am entitled to ask whatever questions I like and make use of 21 l 22 the time in whatever way I see fit.
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29296.0 cox 59 1 BY MS. MONAGHAN:
2 Q Does your theory of normal accident, Dr. Perrow, 3 -apply to the FEMA exercise?
4 A I don't know enough about that exercise yet to be 5 sure, but it might. It might.
6 Q At this time do you have any idea what the 7 application might be?
8 A Not really, except that there were multiple 9 - h nc-a d-multiple failures and they interacted. Very 10 general, 11 Q Is the concept of normal accident limited to an (3
\ <
12 interface between human beings and complex, high-risk 13 technologies?
14 A Limited to what -- what do you mean?
15 Q As I understand, the normal accident theory deals 16 with high-risk technologies and human error--
17 A Right.
18 *Q -- and the interaction of those two systems; is 19 that correct?
20 A Yes. You are asking if it's limited to that.
21 Q That's right.
22 A I guess -- no. Except that if you have an C)
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s-1 organization, you cannot have just hardware. You have to 2 have people, because people will have had to design the 3 hardware, in the hierarchy of the organization, as far as I 4 am concerned. So if you are saying can you have a normal 5 accident without any human intervention in that accident, 6 while'the occasion for it goes on, yes. But the design of 7 the organization and the design of the equipment and the 8 decision as to where to put the people and so forth, is a 9 case of human behavior. So, do you see my problem? It's not.
10 limited to hardware interaction because people put the 11 hardware there.
p_
! I
If the hardware were not present and we were just 12 Q 13 talking about a people organization, does your normal 14 accident theory apply to a people organization absent the 15 high-risk technology?
16 A Yes. On the other hand, I can't imagine that 17 either, because people stand, sit, walk, drive and talk; and 18 there's ambient noise. They may talk and not hear one 19 another. So it's not limited to people, but includes the 20 environment and the tools they normally use.
i 21 Q Dr. Perrow, I am not sure I understand your answer i 22 , to the prior question. Does the normal accident -- does your i
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x 1 thesis about the normal accident apply to situations where 2 organizations are not dealing with a high-risk technology,.
3 where the high-risk technology is not present?
4 A Oh, I am sorry, I did not really -- I wasn't 5 following. I got intrigued by what you were saying. I am 6 sorry.
7 MS. LETSCHE: You can be intrigued, but just 8 answer the question, Dr. Perrow.
9 THE WITNESS: Yes. It does apply to those 10 organizations that are not high-risk technology, yes, 11 obviously. You do not need high-risk technology to have a I '
.12 system accident.
13 BY MS. MONAGHAN:
14 Q When you use the term " system accident," is that 15 equal to normal accident?
16 A Normal accident.
17 Q What empirical data do you rely on for your normal 18 accident thesis or theory?
19 A In the book called " Normal Accidents"?
20 Q In the book or in any other research that you may 1
21 l have done or analysis that .'. may have done.
I 22 A Oh dear. I rely on reports of accidents in
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1 chemice.1 plants, nuclear power plants,. nuclear' weapons,
- L ships, marine transport,Eair' transport, recombinant DNA,
, 3' _ technology.
4; Q- And all;of that empirical data and the sourcesgof
-5 it would be outl'ined in your book, "The~f:ormal Accident"?
6 A Oh, absolutely. Yes- .
7l -Q Would you say that your normal accident theory is 8 universally' accepted ~by-your peers in'the-sociological-9 discipline?
I' 10: A I have no idea.
11 Q Do_you think there might be a school of-f%*
') ~ 12 sociologists who would disagree _with that theory?
~
13 A I do-not know of any, but there might'be'.
14' Q Dr. Perrow, I am going to show you a copy of your .
15 article entitled "The President's Commission and the Normal 16 Accident."
- 17 MS. MONAGHAN
- I would ask that it be marked as I Perrow Deposition Exhibit 2.
18 (Perrow Exhibit 2 identified.)
19
! 20 BY MS. MONAGHAN:
21 Q Dr. Perrow, do you recognize this as being an l 22 article which you authored?
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_1 A Yes, yes.
2 Q I-Lwould ask youc to turn to.page.180.
3 IA Yes.
4 Q The last sentence-of the second paragraph on=that~
15 page makes the statement that "In view of these. facts" -- you 6 , are perfectly welcome to; read the' foregoing facts - "a 7- conclusion of severe deficiency in training seems 8 .over-selective and averts our gaze from the-inevitability of 9 an accident even if training were appropriate."
10 At this time do you agree with the statement that 11 is made in this article?
12 A That the conclusion is over-selective, yes.
13 Q Do you also agree with the fact that an accident 14- is inevitable even if training.were appropriate?.
15 MS. LETSCHE: Walt a second. Are you talking 16 about as-stated in this article, or what is your question 17 referring to?
18 MS. MONAGHAN: The concluding statement of this 19 paragraph which deals with the facts of the TMI accident that 20 have been laid out in the pages prior to that concluding 21 statement.
22 MS. LETSCHE: What was the question? I am sorry.
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1 BY MS. MONAGHAN:
2 Q The question is whether Dr. Perrow agrees with 3 that final sentence, which is the concluding sentence, in its 4 entirety.
5 A Yes, I do.
6 Q So, is it your thesis, then, that no amount of 7 training can avert a normal accident?
8 MS. LETSCHE: I object to that question. Are you 9 asking about his thesis as stated in this article? Are you 10 asking about his thesis as statee in that one sentence which 11 you have palled out of one paragraph in this article? Are I'~') 12 you asking about his thesis in the entire world or what?
13 MS. MONAGHAN: Ms. Letsche, I think~my question to 14 Dr. Perrow was perfectly clear. I asked him if this was the 15 article he had written and if he still agreed with the 16 statement in the article.
17 MS. LETSCHE: That's right. He answered that 18 one.
19 MS. MONAGHAN: He stated he did.
20 MS. LETSCHE: I am objecting to the follow-up 21 question, which I think was vague and ambiguous.
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%l 1 BY MS. MONAGHAN:
2 Q I don't think the question was vague. Do you have 3 a problem with the question, Dr. Perrow?
4 MS. LETSCHE: Why don't we have it read back.
5 THE WITNESS: Yes.
6 BY MS. MONAGHAN:
7 Q I will repeat the question. Is it your thesis 8 that no amount of training c an avert a normal accident?
9 MS. LETSCHE: I have the same objection to that 10 question.
11 THE WITNESS: Yes.
(~h
'~') 12 BY MS. MONAGHAN:
13 Q Was it your thesis at the time that you wrote this 14 paper?
15 A I don't understand the question. I cannot respond 16 to the question the way it's posed. Normal accidents have 17 multiple causes and poor training is only one of many.
18 Therefore, I cannot say that removing one of the multiple 19 causes would prevent or avert an accident. It doesn't make 20 sense to me. If you are saying can you have accidents even 21 if you have excellent training, I would say yes, you can, 22 because there are other causes of the accidents.
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%f 1- Q So that excellent training, even~if the training- 1
-2 were completely appropriate, wouldn't necessarily avert a; 3 normal accident?
4 A Let's-see now. Let's try that. The way you-5 phrase it is not the way I usually th' ink about'it. So, 6 excellent training would not necessarily avert a normal 7 accident. I would only say yes if I could add to that,- l 8 _ excellent training would not avert a normal accident that was 9 due to the failure of the environment or the design or the:
10 procedures or the operator's attention or whatever.
11- There are multiple causes to these accidents, and~
o n bj A1r 12 training is.enproper.
13 Q In your opinion, is11t possible to eliminate all 14 causes of a normal accident?
15 A No,'it is not.
i
- 16. Q Dr. Perrow, will you look at page 183 of this i 17 paper that is Perrow Deposition Exhibit Number 2?
i-i- 18 A Yes.
f i 19 Q I would ask you to look at the last three 20 sentences on page 183 beginning with this phrase: "But it 21 stops short of recognizing how a nuclear power system is p
22 inherently prone to accidents regardless of our efforts."
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29296.0 cox 67 t i m-1 A Okay.
2 MS. LETSCHE: You may read anything else you want 3 to read.
4 THE WITNESS: Yes. I read the previous two 5 sentences. Yes, I read it.
6 BY MS. MONAGHAN:
7 Q Okay. Would you say that the statement here that
'8 even if all of their recommendations, meaning the 9 recommendations of the commissioners, NRC commissioners, were 10 taken by the industry, we still have tightly coupled, complex 11 systems whose potential for catastrophe is enormous?
(,)
12 A Yes, I did.
13 MS. LETSCHE: Let me just correct for the record.
14 I don't think the reference is to NRC commissioners.
15 THE WITNESS: Oh, good for you.
16 BY MS. MONAGHAN:
17 Q Dr. Perrow, what was the reference to, which 18 commissioners?
19 A Let me read it here to make sure.
20 . Q Were those individuals commissioners of the i
21 l President's commission appointed to study the TMI accident?
I 22 ! A The sentence, if read -- yes, it would be the
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1 President's commission. Even if all the recommendations of 2 the President's commission are taken seriously, we will still 3 have tightly coupled systems whose potential for catastrophe 4 is enormous. Yes, I still agree with that. It doesn't say 5 that much, though, if you look at it very carefully. .
6 g That concept and statement would apply to all 7 nuclear power plants; is that right?
8 A No. It applies to all nuclear power plants that 9 we now have.
10 Q By "now," have you -- meaning all of those who 11 have been constructed, whether or not they are currently
\' '>
12 licensed and on line or prior to receiving your license?
13 A Yes, yes.
14 Q Dr. Perrow, you have also written on the 15 organizational context of human factors.
16 A Yes, much.
17 Q What does that term mean, " organizational," or 18 ,
collection of terms, " organizational context of human 19 factors"?
i 20 i A Well, I will be glad to talk about it. Human l
1 21 factors engineers are engineers who are hired to deal with 22 the interface between the human and the technical system that
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I they have to operate on. Those' engineers exist in an 2 organization, and that's the organizational context. So do 3 the operators and so does the technical system that they are 4 to deal _with, because it's designed generally by people 5 within that organization.
6 So the phrase means that instead of just looking 7 at human factors, engineers and operators, as two isolated 8 and discrete entities, you have to look at the organization 9 that they are embedded in, and that includes a lot of 10 factors.
11 Q Will you be applying your work on the 4
{';
12 organizational context of human factors to the testimony 9
13 which you are going to give in this proceeding?
14 A I just don't know. I really do not have my 15 testimony worked out.
16' Q Dr. Perrow, in connection with four testimony in 17 this proceeding, have you spoken with Gary Simon?
18 A No.
19 Q Do you know who he is?
20 A No. Oh, I have heard his name, but I haven't 21 spoken with him. I don't know who he is, either.
22 Q You have heard of him; is that a correct O
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2 A Yes.
3 Q Have you spoken with Stephen Cole at all?
4 A No.
5 Q Do you know Stephen Cole?
6 A Yes.
7 Q Did you work with Stephen Cole when you were at 8 Stony Brook? -
9 A No.
10 Q Is your knowledge of Stephen Cole based upon your 11 affiliation at Stoney Brook?
!'~') 12 A Yes.
13 Q Have you spoken with John Streeter about the 14 testimony you are going to give?
15 A No.
16 Q Do you know who he is?
17 A No.
18 Q How about Peter Cosgrove?
19 A No.
20 Q You have neither spoken with him or know who he 21 is?
22 l A The name "Cosgrove" I remember from some of the O
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1 testimony, testimony at the prior hearing, whatever.
2 Q The hearings on the emergency plan. You believe 3 you have reviewed some testimony?
4 A I think he was a police officer.
5 Q That's correct.
6 A Yes.
7 Q Your knowledge of Peter Cosgrove was based on your 8 review of some testimony that you recall he either gave or 9 was mentioned in?
10 A Yes.
11 Q Do you recall whether he gave that testimony?
12 A No, I don't, as a matter of fact. I think he 13 did. I think he was listed with a whole bunch of people at 14 the top in caps. But sometimes that testimony didn't say 15 Cosgrove says this or Jones says this, or something like 16 that.
17 Q So that he was probably one member of a panel of 18 witnesses who came to testify?
19 A Yes, I imagine that's right.
i 20 j Q All right. Have you discussed the testimony you 21 j will give in this proceeding with Elizabeth Loftis?
c 22 A No.
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l 1 Q Do you know Elizabeth Loftis?
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2- A No.
3 Q What about Frank Petrone?
4 A No.
5 Q What about Lee Coldwell?
6 A What is the question?
7 Q Have you discussed your testimony with Lee 8 Coldwell?
9 A No.
10 Q Do you know who Mr. Coldwell is?
11 A Yes.
(
12 Q What is your knowledge of Mr. Coldwell?
13 A I believe he is a former FBI official. Is that-14 the right person?
15 Q That's correct, to the best of my knowledge.
. 16 A Okay.
17 Q Did you have any discussions with Mr. Coldwell 18 about the testimony you are going to give?
19 A No.
20 -
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I therefore are protected by the attorney work product 2 doctrine.
i 3 MS. MONAGHAN: I think the witness has already 4 answered that he had no discussions with Mr.'Coldwell.
5 THE WITNESS: Yes, sorry.
6 BY MS. MONAGHAN:
7 Q Dr. Perrow, I think we have establi'shed that you 8 have reviewed some of the contentions, the ones on which you 9 expect to give some testimony, and that you received the 10 contentions. Some were in the late November, early December 11 time frame; is that correct?
A
(
12 A I think early in December. I don't think I got 13 them before then.
14 Q Do you -- for legal reasons, there have been 15 modifications made to the text of the contentions. Do you 16 know whica draft of the contentions you reviewed?
17 MS. LETSCHE: I can tell you that. He reviewed 18 the original as-filed one.
- 19 MS. MONAGHAN
- August of 1986 as-filed version?
20 l MS. LETSCHE: Yes.
l 21 l BY MS. MONAGHAN:
22 Q Dr. Perrow, I am going to show you a copy of the l(1) ,
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2 A Shall I open this up?
3 Q You may open it up.
4 A Am I to be using it?
5 Q You are to be using it.
6 A Okay.
7 Q I understand from Ms. Letsche that this is the 8 version of the contentions which you reviewed. I will ask 9 you to turn to Contention Number 15.
10 off the record for a moment.
11 (Discussion off the record.)
12 MS. MONAGHAN: Back on the record.
13 BY MS. MONAGHAN:
14 Q Dr. Perrow, do you have an opinion about the 4
15 issues raised in contention 15?
16 A Yes, I agree with the conclusions of the 17 contention.
18 Q What do you base that opinion on?
19 A The evidence provided in the contention.
20 Q Do you rely on any facts outside of the evidence 21 provided in the contention?
22 ! A No, other than that there is support for many of i
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1 the points in the FEMA document that I have glanced at rather 2 quickly.
3 Q So you would also rely on the FEMA post-exercise 4- assessment; is that correct?
5 A I would rely on it for the occasions when the 6 contention relies upon it.
7 Q Do you rely on any sociological texts or treatises 8 for your opinion?
9 A I don't think we need to go that far. This is not 10 mysterious. I would say this is pretty obvious.
11 Q So there is no particular text or treatise on
' which you would rely?
12 13 A No.
14 Q In your opinion, what does the phrase "the scope 15 of the February 13 exercise of a LILCO plan was so limited 16 that it could not and did not yield valid or meaningful 17 results on the implementation capability as required by 10
, 18 CFR 5047 ( A) (2) mean"? That's a direct quote from the first 19 sentence of Contention 15.
20 A It means that apparently 10 CFR certification 21 requirements were not met and that it predicts a certain i
22 j scope, and that scope was not present in the exercise, f^)
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1 Q Are you familiar with 10 CFR 5047 (A) (2)?
2 A No.
3 Q In your opinion, what critical aspects of the 4 off-site emergency plan were not exercised that needed to be 5 exercised?
6 A I am sorry. I don't understand that.
7 Q You said that you agreed with the statements in 8 Contention 15 in that I believe you said that in your opinion 9 the FEMA exercise was so limited that it could not yield 10 meaningful results; is that a correct recharacterization of 11 your opinion?
12 A No.
13 MS. LETSCHE: I think what Dr. Perrow said was 14 that he agreed with the conclusion stated in Contention 15.
15 THE WITNESS: Okay. The ccope was too limited to 16 yield valid or meaningful results, and the contention 17 specifies those occasions, like those occasions of public 18 evacuation of 850 patients from hospitals, actions by the 19 Coast Guard, et cetera.
20 (Discussion off the record.)
i 21 l MS. MONAGHAN: Back on the record.
22 l 1
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1 BY MS. MONAGHAN:
2 Q Dr. Perrow, in your opinion, what major portions 3 of a LILCO plan were not demonstrated which must have been 4 demonstrated?
5 A I would say all of them. I don't know of any.that 6 -- well, FEMA has said that some things were acceptable, and 7 I would say that those that were not acceptable were major 8 portions of the plan that were not demonstrated.
9 Q So you are relying on the FEMA exercise assessment 10 and what FEMA characterized as unacceptable for your 11 conclusions about what was unacceptable?
, (""
12 A Yes. ,
13 Q Yes. Do you know whether FEMA determined 14 precisely what aspects of the LILCo plan would be exercised?
15 A State that again, please.
16 Q Do you know whether it was FEMA's decision as to 17 which aspects of the emergency plan would be exercised?
18 A No, I don't. I don't know that.
19 Q Do you know whether FEMA made a decision to 20 exclude any portions of the LILCO plan from the exercise?
21 A No, I don't know that.
22 Q Would it make a difference to you whether it was O
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1 FEMA's decision as to whether or not to include or exclude 2 certain portions of the plan from the exercise?
3 A Make a difference to me in what respect?
4 Q In terms of whether or not, in your opinion, the 5 exercise was so limited it could not yield meaningful 6 results?
7 A No.
8 Q It would not make a difference to your opinion?
9 A If I understand what your line of questioning is, 10 if FEMA said that we do not need to worry about evacuating 11 people from the hospitals in this exercise, and thus did not f'~) 12 test it, I would say that their decision not to have that 13 tested would not influence my opinion, that the lack of that 14 testing, I think it's so complicated, demonstrated that the 15 limited scope -- do you understand what I mean?
16 Q I think I do.
17 A Okay.
18 Q Is it your opinion that every aspect of the LILCO 19 plan would have been demonstrated during the exercise?
I 20 Before you answer that question, let's make a distinction 21 between the term " demonstrated" and the term " evaluated."
22 When I use the term " demonstrated," I mean that the LERO
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%wd 1 players performed the functions that they were supposed to be 2 performing; and whether or not you think they performed them 3 correctly or incorrectly is not the point, but they went out 4 to perform those functions. When I use the term " evaluated,"
5 I mean there was a FEMA observer present to observe what they 6 did and to make an assessment of whether or not their 7 performance was correct or incorrect.
8 A Good.
9 Q In your opinion, in order for the FEMA exercise to 10 yield meaningful results, would every asnect of the exercise, 11 every aspect of the LERO plan, have had to have been
\
12 demonstrated?
13 A Yes.
14 0 Would every aspect of the LERO plan had to have 15 been evaluated by FEMA?
16 A Yes.
17 Q So, in other words, if there were 66 bus drivers 18 ,
that are expected to run general evacuation routes to pick up 19 persons who did not'have their own vehicles, in order for the 20 ;
exercise to yield meaningful results, in your opinion, would 21 l it require that all 66 bus drivers drive buses, run the 22 routes and be evaluated by PEMA observer?
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1 A' No,-I didn't think I, meant that, no'. Sampling is 2 allowed.
3 Q How would you go about determining what the-4 appropriate sample size would be?
I 5 .A I don't know yet. I would have to' examine the 6 task, the difficulty of.it, training the personnel, 7 circumstance under which they operate -- in order to say 8 whether we should have a 5-percent, 20-percent or a 9 50-percent sample. I think all of those -- I picked those 10 numbers out of the blue; but I think in some-cases-you would-11' want a 50-percent sample just from the evidence.we have.
12 Failure rate was so'high in some cases that we really should
^13 have a fairly heavy sample.
14 Q How would you have determined prior to knowing
. 15 what the failure. rate was, what the sample size should have 16 been?
17 M S ~. LETSCHE: You are asking how Dr. Perrow would-18 have designed this' exercise; is that the question? If'that's
- 19 the question, then I object.
20 BY MS. MONAGHAN:
21 Q I am asking Dr. Perrow -- he has testified that he 22 feels that the FEMA -- in his opinion the FEMA exercise was O
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1 so limited it couldn't yield meaningful results, that in some 2 Instances the sample size was too small. Is that to yield-
,; 9 .3 ' meaningful results? L 'au trying to determine what the. sample 4 ' size should be in his opinion to yield meaningful'results.
5 MS. LETSCHE: I think he has already answered that.
6 question.
E 7 THE WITNESS: Yes. As I'said, I would examine the 8 task of the people involved, in training, the context of 9 that. I would make a very careful determination of!the-10 behavior expected and the environment in which it-occurs 11 before I decided:how closely we should broadly sample that IO 12 activity.
13 BY MS. MONAGHAN:
14 Q In determining the appropriate sample size, would 15 you look to'the number of persons who were performing the-16 function-as one of the criterion you would use?
17 A Yes.
- 18 Q Nould you be concerned as.to whether or not the 19 sample size that you took would be statistically valid?
20 A Would I be concerned? I would certainly.be 21 concerned if it were statistically ir-relevant, but I am not 2
22 sure what statistics you are talking about. You would have i
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wi i to specify the kinds of statistics. There's a variety of 2 statistics, and I would want to know which ones you are 3 talking about.
4 Q What I am driving at here, Dr. Perrow, is how you 5 . would sample in order to be sure that you had a statistically 6 significant level of confidence in your results.
7 MS. LETSCHE: Let me just -- we need a 8 clarification. I thought you were initially asking questions 9 about Contention 15. Have you now switched over to 10 Contention 21?
11 MS. MONAGHAN: No, I have not.
~ - 12 MS. LETSCHE: Then I don't have any problem with 13 Dr. Perrow answering your question, if he is able to. But I 14 do object to your asking him hypothetical questions as to 15 what he would do, without giving him the assumptions that he 16- has told you that he would need to have and has explained to 17 you, what kind of analysis he would go through if he were 18 coming up with some sampling. I-just want to instruct him 19 that he shouldn't be speculating in a vacuum in response to 20 your question.
21 THE WITNESS: Yes. I would like to know more 22 about the kinds of statistics you are speaking of.
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29296.0 cox 83 I) 1 As I recall, you are asking me, how will I 2 determine the size of the sample?
3 BY MS. MONAGHAN:
4 Q That's right.
L 5 A It depends upon the measurement.
6 Q What do you mean by "it depends upon the 7 measurement"?
8 A Depends upon how much of a behavior -- a sample is 9 a person. We normally say we have 100 people and we are 10 going to sample 20 of them. But that's a very crude 11 indicator. You might'have 100 people who only have to do one p_
i 4
'~# 12 thing: point in the direction of the Coliseum. That's the 13 only behavior they are expected to do, and that behavior then 14 is -- maybe there is 100; it is unbelievable but-it's 100 15 -behavior acts.
16 Whereas in another case you might have a person 17 who is expected to redirect traffic around a bottleneck or a 18 crash, check their dosimeter, call in to their coordinator, 19 advise the people who stop and say what is going on, what is 20 the latest, where should I go, should I go back and get my 21 husband or not, I am not sure whether he has the car or not, 22 I haven't seen him, and all those types of things. If you (V
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1 then have maybe roughly ~800 possible acts of discrete enough-
.2 character that people could make decisions about,1could do 3 .them rightly or wrongly, then you have a different= sample z 4 size.
4 5' So'if you say what sample size, it depends upon i
l 6 what you are sampling. I really couldn't be more specific 7 than that.' We have experts, you know, who look over: stuff 8 and say this is an inappropriate sample for this complexity.
9 ~of behavior; and you really kind of have to look at this very
+
10 carefully.
11 Q Dr. Perrow, would you turn'to contention 22?
O 12 A. Yes. Could you give me the page.
13' Q I am trying to find it.
i 14' MS. LETSCHE: I think it's 62.
15- MS. MONAGHAN: Yes,.it'is page 62.
p 16 BY MS. MONAGHAN:
i y o. .17 .Q Now, as I understand it, Dr. Perrow, you are to 18 provide testimony on Contention 22; is that correct?
- 19 A Yes.
20 Q Are you to provide testimony on all the subparts 21 of Contention 22 or only some of the subparts? You will 22 notice that Contention 22 contains subparagraphs that are O
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2 A Yes.
- 3 Q A through K.
4 A I am not sure. State your question again, 5 please.
6 Q Do you expect that you will be asked to provide
~i testimony on all the subparts of Contention 22?
8 A I am not sure what I will be asked.
9 Q By examining the subparagraphs of Contention 22, 10 can you determine whether or not you have an opinion about 11 the various subparts? Let's look at paragraph A.
12 A Paragraph A?
,,_ 13 Q Yes. I think you probably need to read the 14 prelude.
15 h A Oh, yes, this is one of the assumptions. Now, 16 what was your question again? I am sorry.
17 Q Do you agree with the statements in subparagraph 18 A?
19 ; A Yes, I do. The assumption is false.
20 f Q What facts do you rely upon for your opinion that 21 l the assumption is false? First let's establish what you 22 consider to be the false assumption.
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1 A That the Coliseum will be available for'the 2 purposes laid out; and the evidence follows in.the next two 3 sentences later. Nassau County has expressly refused to
~
4 agree or permit use-of Nassau County facilities as a part of 5 or to implement the LILCO plan, and it references to County 6 Board of Supervisors Resolution No. 782 B-1986.
7 Q In-your opinion, why is the use of the Nassau 8 Coliseum during the exercise -- why does the use of the 9 Nassau Coliseum during the exercise preclude a finding of 10 reasonable assurance that the plan can be implemented?
11 A It doesn't have to be the Coliseum, but you need f_ i 12 some reception center for all of these people or'several of 13 them, and they have said -- they have no alternative, at 14 least at this time, to using the Coliseum.
15 Q Do you know whether LILCO has identified an 16 alternative to the Nassau Coliseum?
17 A No, I do not.
18 Q So at this time you don't know whether the 19 statements that were made in these contentions drafted in 20 August 1986 are still correct?
21 A No, but I would think that would be irrelevant, 22 because aren't we dealing with the exercise that was s
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' I conducted on February 3, 1986, and that exercise anticipated 2 -- reception center was not available.
3 Q Do you know whether the reception center was 4 available for use the day of the exercise, the Nassau 5 Coliseum?
6 A I assume it wasn't.
7 Q You assume it was not available on the day of the 8 exercise?
9 A Yes.
10 Q Do you know whether the -- during the exercise the 11 LERO organization employed anything as a reception center and i
\'#' demonstrated the mobilization setup and use of a reception 12 13 center?
14 A I am not sure. I am sorry. I don't remember that 15 part of it. I didn't really look at that part of the FEMA 16 report.
17 Q Do you know whether you are going to be offering 18 any testimony on this particular subpart of the contention?
19 A I am not sure. It's quite possible.
20 Q Dr. Perrow, if, in fact, the Nassau Coliseum had 21 been demonstrated as a reception center, its use had been 22 demonstrated as a reception center the day of the exercise,
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- ty 1 would thatichange yourfopinion?
~21 MS. LETSCHE: :What opinion?;
. 3' THE WITNESS: Yes, wh'at opinion'?
I ll BY MS. MONAGHAN:
5 Q Would it change your opinion that the exercise --
6 that t'he Nassau Coliseum used as a reception center --' excuse 7 me, strike that.
'8 If, in fact, the Nassau Coliseum was used on the^
9 day of the exercise as a reception center, would it change 10 your opinion that-the exercise does not. permit a finding of 4
11 reasonable assurance that the LILCO plan can be implemented-10 12 based on the reception center' issue?
13" A Let me think about that. That's a tough one. RNo ,
14 because if it were.used at that time, I don't know the; 15 circumstances-under which it was used; and tho'se 16 circumstances-might not be-present at a future time,.
~
17 especially!if as notified here that Nassau County Boardcof 18 Supervisors has expressly refusedoto. permit the use of Nassau 4 .19 County facilities. I would assume for the plan to be i: .20
. successful that there would nave to be reception centers 21 where there was no doubt that they could bring contaminated 22 people to and so forth. There was just no doubt. -Not where LOL ACE-FEDERAL REPORTERS, INC..
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1- they.were located. 'There wasn't a -- Johnny Cash'show going
. 2 on at that time or Rolling Stones or something. You have'to 3 be sure that you --- that would be important .to -me.
4 Q. Dr. Perrow, are you taking issue ~with the'use:of 5 the'Nassau Coliseum as an appropriate place for a reception 6- center?
b 7 A No.
.. -8 Q Are you taking. issue with the fact -- strike 9- that.
V LO In your opinion, would the exercise have to 11 include a demonstration of the reception. center that would
'12 actually be used in the event of.an emergency?
f 13 A Yes.
14 Q Do you know whether the functions that are to be 15 performed.at the reception center would differ depending upon 16- the location of the reception center? -
i 17 A I would hope not.
18 Q You would hope not?
19 A I would hope not, no . . I assume that you have
-20 functions that need performing. Then you find the place.
21 You don't find the place and tailor the functions to the 22 place, n(_/
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1 Q Let's look at subparagraph B. Do you know whether 2 you are going to be expected to offer testimony on 3 subparagraph B?
4 A I am not sure, but I imagine so.
5 Q Do you agree with the statements in subparagraph 6 B?
7 A Yes.
8 Q On what facts do you rely on for your opinion that 9 the -- excuse me. What facts do you rely on for your 10 treatment with.the issues raised in Contention 22 sub B?
11 A FEMA report at 38 and 43.
( )
12 Do you rely on any other facts?
Q 13 A No.
14 Q Do you rely on the FEMA report at 38 and 43 15 because those are the pages that are cross-referenced in this 16 contention?
17 A Yes. But I also looked at them.
- 18. Q Do you have independent knowledge of what is 19 contained in the FEMA report at pages 38 and 43?
20 A Yes. That's one that I checked.
21 Q What did the FEMA report conclude about school 22 dismissals?
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29296.0 cox 91 (v) 1 A That it hadn't been exercised.
2 Q Do you agree --
3 A I think that there is other evidence on that. I 4 am sorry. I was. neglectful. I have seen some of the 5 statements by the school officials saying that.they could not 6- do these various things, such as early dismissal.
7 Q Were the statements from the school officials that 8 they could not do those things or they would not do those 9 things?
10 A I am sorry. I think it was that they would not, 11 but I think it wa also that they could not. But I am not d 12 sure.
13 Q Do you agree with the statement in Contention 22-C 14 that there will not be a sufficient number of bus drivers 15 available and willing to drive school buses during the 16 accident?
17 A Yes.
18 Q What do you base that on?
19 A "At the latest count, 198 out of 363 bus drivers 20 from all school districts in the EPZ," et cetera, et cetera.
21 The information is presented in the contention.
22 Q Do you have any other independent factual bases?
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1 MS. LETSCHE: Other than the facts that are set 2 forth in the contention itself?
3 BY MS. MONAGHAN:
4 Q That's right.
5 A Not at this time. No.
6 Q Have you reviewed the certifications assigned by 7 the school bus drivers?
8 A No.
9 Q So that you are just -- you are relying solely on 10 the statement in the contention?
11 A Yes.
[')
\ Let's skip to contention 22-F. Is it your opinion 12 Q 13 that exercise players should not have assumed that members of 14 the public would follow LERO's protective recommendation 15 actions?
16 A Yes.
17 Q What do you base that opinion on?
18 A The evidence cited in the contention.
19 Q What evidence specifically cited in the 20 contention?
21 A Let me find it here. " Survey research data."
22 0 What survey research data?
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1 A Oh, a study _that is referenced in other 2 contentions by Stephen Cole and studies that have been made 3 of the Three Mile Island accident, which are referenced in 4 the prior hearing.
5 Q Have you reviewed the survey data by Stephen Cole?
6 A No. Except insofar as it is in some of these 7 contentions. Perhaps I have seen some summaries of them. If 8 it was in the previous, it probably was, in the previous 9 litigation, then I have seen some data from that asking 10 people what they would do and giving the percentages yes.
11 Q But you haven't independently reviewed the survey 7 ~.
12 itself?
13 A In detail, no.
14 Q Have you reviewed the methodology used by Stephen 15 Cole in conducting the survey?
16 A No.
-17 Q Could you in any way attest to the validity of the 18 survey data?
19 A I can attest to Stephen Cole's competence. It's 20 enormous. He is one of the best there is. If he did a 21 . survey, I would think that it would be one of the best l
i 22 I surveys that's been done,
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O'ther'than your confidence in Stephen dole's 1 .Q 2 abilities to conduct ~a good survey,'you'have not
~
3 lindependently reviewed the survey and'made a separate -
- 4. ' assessment of its validity?
5- A I said that.
6~ MS. LETSCHE: That's been asked and answered.
7 THE WITNESS: I said that.
8 BY MS. MONAGHAN:
- 9 -Q Which.of the TMI-accident studies do you rely.on-
-10 for your statement that the exercise players should not have 11 ' assumed that members of the public would follow LERO's
~
12 . protective. action recommendations?
13 A The President's commission report, the research by
/
14' ' J o h'n s o n , the research by -- I'think it's Ed Walsh,.I don't-15 recall. There are several studies.
16 Q To your knowledge, are there also studies which
< 17 indicate that it is safe to assume that the public will
, 18 follow protective action recommendations from an entity.such 19 as a utility organization or an off-site emergency response.
20 organization?
21 MS. LETSCHE: Are you referring to the TMI Y
f 22 accident still when you say " studies"?
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1 MS. MONAGHAN: No, I am not limiting it to the TMI 2 accident.
3 THE WITNESS: Better repeat that question for me, 4 if you-could.
5 BY MS. MONAGHAN:
6 Q Are you aware of other studies of. accidents or 7 emergencies which indicate that the public would follow 8 protective action recommendations?
9 A Not in the case of nuclear accidents.
- 10. Q Do you, in your opinion -- will the public's 11 behavior in the case of a nuclear accident be different than t 1 12 its behavior in the case of a national natural disaster?
13 A All I can say on that is that we have only had 14 one, and so we don't have a data base. So the question is 15 still open; and we can say with certainty, I think, that it 16 hasn't been confirmed that the response will be the same.
17 Q In your opinion, would the public's response to a 18 nuclear emergency be the same or different than its response 19 to a chemical spill-type accident?
l 20 MS. LETSCHE: If you have an opinion on that, you 21 may give it.
22 THE WITNESS: I am not sure now at this point, but U
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_1 Ifwould-have to have it more:specified. I could conceive' of-
~
.2- chemicals -- of a chemical spill that' included an invisible 3 odorless. vapor cloud that was extremely toxic which shifted?
4 -with the wind, which was hard to track, not seen'by people.
5 There might be some. similarities there.. But I.think in 6 _ general there probably would be a difference.
7- BY MS.'MONAGHAN:
8 _Q Wh'y'do you suspect there would be a difference?
9 A Because it's hard to get _the kind of a : chemical 10 spill that will produce something with the'_characteristicsoof 11 ionizing radiation.
~
12 Q Are you familiar with the accident in Mississauga?
-13 A Yes.
- 14. Q Would you consider that to be the kind ofichemical.-
15 spill accident in which there was an invisible cloud?.
16 A No.
17 MS. MONAGHAN: Off the record.
18 (Discussion off the record.)
19 MS. MONAGHAN: Back on the record. Let the record
~
-20 show that during the break the witness was conferring with 21 e counsel.
22 O
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g V 1 BY MS. MONAGHAN:
2' Q .Dr. Perrow, have you' conducted'any research 3 studies or analyses yourself which-would lead you tofb'elieve s 4~ Lthat the public would notffollow LERO's protective.. action-5 . recommendations?
6 A No. ,
7 Q .Is.it our opinion that it d.e accident that was.
4 i 8 postulated-in th'e exercise actually occurred and the 9 activities of the LERO players in response to that accident
=10 had actually been taken, that evacuation by the public, both; 11 inside and outside the EPZ, would have started much earlier-p-
\- 12 than it did,_than it was predicted in the' exercise?
13 MS. LETSCHE: Let me just object. I don't know 14' what you are talking about,sthan it-did during the' exercise.
~ ~
15 There wasn't any evacuation during the exercise.
16 BY MS. MONAGHAN:
i
- '17 Q That it was assumed an evacuation would have
- 18 occurred.during the exercise.
19 MS. LETSCHE: You mean when the LERO people would' I
- 20 i
~
have assumed it would have occurred?
21 BY MS. MONAGHAN:
22 Q Do you understand my question, Dr. Perrow?
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1 A No, it's difficult, because there was no 2 evacuation. I don't recall that LERO;did anything other than 3 assume that they evacuated immediately after 10:54, whenever 4 that time was; is that right? Okay. I am kind of asking 5 myself. Okay, ask your question again.
6 Q Is it your opinion that if the accident postulated 7 in the exercise actually occurred and the activities taken by 8 the LERO players had actually occurred, that the public 9 evacuation would have started earlier than was assumed during 10 the exercise?
11 A Yes.
[ 'l#
12 Q Please list f'r me the facts on which you rely in 13 your opinion.
14 A The same ones that we were talking about that's in 15 that contention a.nd other contentions, but in that context.
16 Q Just so I am certain that we are dealing wi th. the 17 specific facts on which you rely, could you relist then for 18 me?
19 A I thought we went through that, but that's all 20 right. " Survey research data."
21 Q By " survey research data" you mean the data by i
22 Stephen Cole in his surveys; is that correct?
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1 A Also by Johnson and also by Walsh and also the .
1 1
2 information presented in the President's commission on-Three. -
1 Mile Island, supplementary documents'.
3 There may be others, 1
4 but that's what I am familiar with now, as I said. !
i 5 Q The supplementary documents to which you refer, 6 those were supplementary documents to the President's 7 commission report; is that correct?
8 A Yes.
9 Q Is it your opinion that public, response to the 10 nuclear accident at Chernobyl demonstrates that voluntary 11 evacuation would occur in a nuclear incident?
e 12 A I haven't examined what happened at Chernobyl, so 13 I have no opinion.
14 Q All right. Is it your opinion that LERO could 15 have responded in any way which would have limited a 16 voluntary evacuation?
17 MS. LETSCHE: You are asking for him to speculate 18 on other things that LERO could have done during the 19 exercise; is that what you are asking?
20 BY MS. MONAGHAN:
21 Q I think the question was clear. Do you understand 22 the question, Dr. Perrow?
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'Q) 1 A No, I am asking whether you --
2 Q I will rephrase the question.
3 A Yes.
4 Q I believe that you have expressed the opinion that 5 a voluntary evacuation would occur in the event of an 6 accident at the Shoreham nuclear power station; is that 7 correct?
8 A Yes.
9 Q In your opinion, is there anything that LERO as an 10 off-site response organization could do to limit a voluntary 11 evacuation?.
p\
12 A Let me answer quite carefully. LERO could 13 decrease the number of people who would evacuate before they 14 were ordered to, but could not eliminate it. I am not sure 15 how much they could even decrease it, but they -- I am sure 16 that they could do better, but I don't know how much 17 difference it would make.
18 Q How could they decrease the number of people who 19 would evacuate before being ordered to evacuate, in your 20 opinion, Dr. Perrow?
21 A Well, there are a number of things. They could 22 reestablish credibility, which might take, say, five years,
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- 0. -- 1 'with theLpublic. .They.could demonstrate that'they have 2 cooperation.with radio stations;-but~it's hard.to answer your..
.3 " question, because there'was no.evacua't' ion. They ' didn ' t ---
4 .the exercise -- they didn't attempt to' evacuate. people.
5 .Now, you are-asking about some fictitious
-6 -hypo'thetical. event that is not'relatedLto the exercise;4is.
7 that-right?
8 Q That's right. That is not specifically related to E 9- the events that occurred on the day _of the exercise. I asked r
10 you whether it was possible for the organization-to~limito
.1 1. voluntary evacuation ~, and you said, well,; they couldn't
- D 1 " 12 eliminate it. entirely but there would be. things;they'could do 13- to decrease it.
14 A Sure.
V l 15 -Q My question to you is, what can they do to 16 decrease it?
17 A They can.have more credibility. They can send out
- 10. very clear messages, noncontradictory messages. The messages l 19 .can be prompt. The rumor control center can give prompt 20 responses. The information in the messages can be complete 4
21 and credible. And, above all, they can get the cooperation 22 of the state and county authorities. I am assuming that they Lg F
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3 Q .So, in your opinion, one.of the things that would 4 decrease the scope of the voluntary evacuation would be 5 cooperation of the state and county authorities?
6 A Yes.
~
7 Q ~ To your knowledge, what segment of the-population 8- -- strike tihat.
9 To your knowledge, what number of people are' 10 likely to-be affect'd:by e the rumor control aspectsLof-the 11 LERO organization? . Members of the public is what'I'am
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12 meaning when I say what number of people.
i 13 MS..LETSCHE: Are you talking about what happened 14 during the exercise; or is this just another hypothetical i 15 question?
v 16 MS. MONAGHAN: This is another' hypothetical 17 question.
18 MS. LETSCHE: I object to that question. It's not i- 19 an answerable question. You can't answer a question like
! 20 that in a vacuum. If you have a particular set of 21 assumptions or facts you want Dr. Perrow to make, fine.
22 THE WITNESS: I couldn't answer that. It's not O:
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tY 1 answerable. Even if the lawyer said it was, I would say no.
2 BY MS. MONAGHAN:
3 Q Dr. Perrow, would the number of people affected by 4 the rumor control function of the LERO organization, in your 5 opinion, be less than the number of people affected by the 6 broadcast of EPZ messages?
7 MS. LETSCHE: Are you talking about in a real 8 accident, during the accident, or what?
9 BY MS. MONAGHAN:
10 Q Do you understand the question, Dr. Perrow?
11 MS. LETSCHE: I would like the question' clarified, c ;
12 please.
13 MS. MONAGHAN: I think the witness is perfectly 14 capable of indicating whether he understands the question.
15 He has had no difficulty in doing that in terms of prior 16 questions.
17 THE WITNESS: Excuse me, I was about to ask, you 18 are still talking about just a hypothetical accident?
19 BY MS. MONAGHAN:
20 Q That's correct.
f l 21 A We are still on that?
22 Q That's right.
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- Y-1 A That's important_for me to'know' . .I-don't1know the
'2 answer;to your' question.
- 3. Q Do you know,!during the exercise that was 4 conducted on-February 13, whether the number'of-persons
~
5 affected by the rumor. control function was greater or lesser-6 'than the number _of persons affected by-the EPZ messages?.
7' MS. LETSCHE: A point of clarification.- I 8 understand during the exercise nobody'was affected by either
,_9 one of those because it was all simulated; isn't that-10 correct?
'11 BY MS. MONAGHAN:
~
.12 ' Q Dr. Perrow, to your knowledge, was-it all.
13 simulated?
14 A Yes.
15 Q So you have no way of judging one way or the other the number of people who would be affected; is thatJcorrect?.
16 17 A On-that exercise, yes.
18 Q You have no way of judging whether, in the event 19 of real' emergency, more people would be affected by an EPZ
.20 - message than would be affected by a rumor control? .,
21 MS. LETSCHE: It's a meaningless question.
22 MS. MONAGHAN: Would you let the witness answer n
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U 1 ithe question, Ms. Letsche. 'If he misunderstands the question 2 '- he;is perfectly. capable of' stating _that. I will rephrase or '
~
3 repeat 1the_ question or try to clarify _the question for him_in 4- some'way.
-5 MS'.LETSCHE:
. Fine. 'I am noting my' objection to-6 the question-as a' meaningless question-since the premise ~of d
P 7 it,-what happened during the exercise, is what happened 8 during the incidents. There wouldn't be-any peopl'e' affected ~
9 by the rumor control or EPZ center. So what would happen 10 during a real accident and whether Dr. Perrow has-any c
11 opinion, speculations or predictions _about.what'would-happen 12 in a real accident based upon that premise is' meaningless. '
v
~
13 .That's my objection. If you want to askfthe question and j: 14 take up all of our time,'that's fine. If Dr. Perrow wishes-F 15 to do that and can do so without speculating, that's fine '
l- 16 too.
- 17 BY MS. MONAGHAN
18 Q I believe Ms. Letsche has mischaracterized'the 19 contents of the question-I asked you, pr. Perrow. Let me 20 rephrase it so we are clear about what the question was.
- 21 I asked you whether in your opinion in a real 22- emergency more people would be affected by EBS messages than
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1 2 A I can't answer that. It doesntt makeisense'to.
3 me.
4 -Q The question doesn't make sense or you -just aren't 5 able-to answer the question?
6 A Both. Insofar as it makes sense, I am unable to 7 answer it. But I can't believe that_my interpretation of~it 8 is the same as yours.
. 9 Q Dr. Perrow, do you think more people hear an EBS a . . .
- 10 message during an emergency than call- into: a rumor control 11' center?
C:) 12- MS. LETSCHE: What kind of emergency are you ,
_13 talking about?
14 BY MS..MONAGHAN: '
15' Q We are talking about an emergency at a nuclear _ ,
16 power plant.
17 A Well, I can say this. What you mean by call in, 18 if you say your question is to try to call in, I don't know.
19 -If you said or succeed in reaching the' rumor control people, 20 it's pretty clear that only a small percentage of them would,
- 21 because telephone lines are limited.
22 Q Would you turn to Contention 41, please.
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);, cox 107 1 Dr. Perrow, have you previously reviewed Contention 41 in 2 connection with preparing for this deposition?
3 A- Yes.
4 Q I believe that you stated that to your knowledge 5 you will be offering testimony on Contention 41; is that 6 correct?
7 A Yes.
8 Q Do you agree with the issues raised in Contention 9 41?
10 A Yes.
o 11 Q Do you intend to offer an expert opinion on
# whether traffic accidents or other events are likely to block 12 13 evacuation roots during an emergency,of the Shoreham plant? _
14 A I am not an expert on traffic accidents.
15 Q Would it be fair to say,.then that since you are 16 not. an expert on traffic accidents you do not believe that 11 you will be offering expert opinion on whether traffic >
w 18 accidents are likely to occur during a Shoreham emergency?'
19 A No, I wouldn't say that at all. I think you don't
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20 have to be an expert on traffic accidents to know -- to get 21 data on the accidents that are likely to occur.
22 Q Do you believe that you will be offering an expert o
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1 opinion on whether traffic accidents are likely to occur 2 during an emergency at Shoreham if --
3 A I will be quoting -- probably doing what the 4 contention does, I believe, or another contention. I will be 5 looking at historical records of the kind of frequency of 6 accidents, before and after the emergency, and offering my 7 opinion. That's a reasonable estimate of what might happen 8 during this particular day. There are several issues that - -
9 on this February day,_they didn't deal with traffic 10 accidents. Presumably, there were traffic accidents, but 11 they were not dealt with. So we wanted to know how many r >
12 traffic accidents were likely to occur on this kind of a 13 day. I would be talking about that, I am sure. I am not 14 sure, but I.think it's poseible.
15 Q You think you will be offering an opinion on how 16 many traffic accidents would be likely to occur?
17 A Yes.
18 Q Even though you are not a traffic expert?
19 A Yes.
20 Q You would be basing your opinion on data that has 21 been assembled about the number of traffic accidents that 22 have occurred on Long Island recently? What is your data
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29296.0 cox 109 1 base, Dr. Perrow?
2 A The number of accidents that occurred in and 3 around the EPZ zone.
4 Q Is that a data base that you yourself have 5 : developed?
6 A I think it's already been developed. I think I 7 read something about it.
8 Q Do you know who developed that data?
9 A No.
10 Q Have you reviewed studies with regard to the 11 number of traffic accidents which occurxed during the EBS?
'm\
# 12 A I saw some statistics on that.
13 Q But you don't know who developed the statistics?
14 A I don't recall, no.
15 Q In offering your opinion about the frequency of 16 the likelihood of traffic accidents occurring during an 17 emergency, will it affect your opinion in any way as to what 18 speeds the vehicles would be traveling during an emergency?
19 A I don't know. Yes, I think if they are driving 20 extremely fast it might make a difference; if you are driving 21 extremely slow it might make a difference. I don't know. I 22 haven't looked into that. It's a good question.
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%f 1 Q: Is it your opinion that-the exercise-demonst' rated:
2 .an ability on LERO's part tofdeal with! traffic impediments?
3' Ai 'Yes.-
4 Q Ih3 you intend to offer expert testimony on that
'5' subject? ,
6 ~A .I think~I will probably.
7- -Q What are the facts -- what are the ' f acts 'cm which; 8 you will rely for your testimony?
9 A .The facts stated in-the FEMA-report and. summarized 10 .in'the contention.
._ 11 Q- Do you intend to rely on'any other facts or
.n
.V 12 documents?
,_ .13 A I may, but I don't know of-them now. I haven't 14; developed my testimony.
. 15 Q In offering your testimony on the ability.or L
f 16 inability of LERO to deal with traffic impediments, do you 17 believe you will be relying on any of your published works?
18 A Are you asking whether I have dealt with traffic
[. 19 accidents in my publishc0 work before?
20 0 No, Dr. Perrow, my question is not whether your i
21 reports have dealt with traffic accidents. To my knowledge 22 they have not; is that correct?
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itc 1 A' .Yes.
2 -Q-
-My question..to you is whether you are going to:be
.3 relying on-the thesis of any'of'your published works'in i
l 4 cconnection'with the. opinion that you are going to be offering-5 .about whether the LERO organization, duringithe exercise, i
[ 6 demonstrated.an inability to deal with traffic impediments?-
~ - -
7 A It's possible.
- . 8 Q Do you have any judgment at"this time whichLofrany-
'9 'of those published-works you might rely on?'
- 10 A No, not particularly'. It's a seamless web. It's 11 hard'to separate from that. It would be hard for me to say<
'$. plyw 12 ato.
13 Q Do you think you would be using your works'which 14' have dealt with the organizational context of human factors?
15 A I might. I don't think so but I might.
16 Q What'about the-body of work that you have written
'17 which deals with the normal accident?
18 A It's possible.
19 Q Do you think it's likely or unlikely?
20 A It's hard to answer that question, because you 21 have a very specific event here, the traffic accidents. You 22 have a very general theory, and that general theory wanders n
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1 in and out of a number of publications and books-and.
2 constitutes kind of a perspective on organizations, events; 3 'and to say which part of that or which book or which 4 reference would bear upon that accident, I just would find it-5 very hard to do. Let's-see if I couldfbe more helpful.
6 These road accidents involve the ability of people to.
7 communicate clearly to move about in a timely manner, to 8 follow orders, to convey information and all these kinds of 9 things that~normally happen in organizations. To pick out 10 any one of those and locate it in the body of work, I just 11 find it very hard to do.
12 Q I am not sure that by your answer you understood 13 the question that I was asking you.
14 A I will try again.
15 Q Let me try it again just to be sure that we are 16 communicating with one another on this.
17 A Yes.
1B Q What I am trying to ascertain, Dr. Perrow, is 19 whether you believe that your body of work, and I think as 20 you have described it, thaory, your particular theory or your 21 particular perspective that you have developed on the normal 22 accident, is going to be a perspective that you will apply to A
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29296.0 cox 113 K ,.Y 1 these traffic accidents; is that the set of glasses, if you 2 will, with which you will look at this traffic-impediment 3 question.
4 MS. LETSCHE: Let me note my objection. I think 5 you mischaracterized the witness' statement. I don't think 6 his prior answer was limited to the perspective in terms of 7 normal accident. I think he was talking about it in terms of -
8 general theory and perspective. I don't think his answer was 9 related to looking at traffic accidents. I think it was 10 related to looking at the responses in traffic impediments 11 which are identified in contention 41.
- (')
12 BY MS. MONAGHAN:
13 Q Let me, based upon Ms. Letsche's statement, be 14 sure that we are communicating again.
15 A Yes.
16 Q What I want to know is whether you are going to 17 apply the normal accident perspective to the traffic 18 l accidents that occur during the exercise, or that were 19 simulated during the exercise, and all of the organizational 20 response to those accidents.
21 A Okay, let me see if I can state that in a way --
22 MS. LETSCHE: Let me note my objection, then you
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w 1 can answer after my objection. That question has been asked 2 and answered. Whether the question was -- I don't know if 3_ 'that precise question was asked but an answer to the question 4 was just provided. You may go ahead and try again, 5 Dr. Perrow.
6 THE WITNESS: My work in normal accidents 7 certainly will be appropriate to every aspect of this -- of 8 these contentions,.I think, or to many of them. Specifically 9 with respect to Contention 40, 41.
-10 BY MS. MONAGHAN:
11 Q I belit ve it's Contention 41.
,a
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12 A With respect to Contention 41, I think it will be 13 used on the contentions, in that contention. I find it 14 difficult to say that the perspective developed in normal 15 accidents will bear directly upon a particular road 16 accident. But insofar as tl.e organization responds to a road 17 accident, I think it will bear. Is that helpful?
18 i Q Yes, thank you.
19 A Good.
20 Q Do you agree with the statement in Contention 41 21 that LILCO's proposal for removal of impediments to 22 evacuation is inherently unworkable?
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1 MS. LETSCHE:
Can you tell me where that is?
2 THE WITNESS: Yes, it's out of context.
3 BY MS. MONAGHAN:
4 Q Bottom of page 117.
5 A Yes.
6 Q Do you believe that you will be offering expert 7 opinion on that issue?. '
8 A Oh, dear. Yes, probably.
9 Q What is the basis for your opinion that LILCO's 10 proposal for the removal of impediments to evacuation is 11 inherently unworkable?
p)
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12 A There was a simulated impediment to evacuation. I 13 think we should insert the word " timely removal" there; and 14 it took them about two hours to find out about it and act on 15 it, sc on and so forth. So that's a very good basis.
16 Q In your opinion, did the responses of the LERO 17 players on the day of the exercise to the two traffic 18 impediments indicate that the LERO plan is inherently 19 unworkable, or that their response to those particular 20 impediments and on that particular day was ii. correct and 21 inappropriate?
22 ,
A Or both.
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1 Q Or both, if it's both.
2 A Both.
3' Q Are there any specific facts on which you rely for
.4 your opinion that the LERO plan's proposal for the removal of 5 impediments is in itself inherently unworkable?
6 A Not as yet. I haven't done that work yet.
7 Developing specific facts. I just want to make sure the 8 question is --
9 Q Do yOu agree with the statement in Contention 41-B 10 that the equipment sent to remove the gravel truck was 11 inadequate and that the time needed to clear that impediment
. /3
! i 12 would have been 30 minutes or more?
13 A Where is that, the statement?
14 Q 41-B, as in boy.
15 A Yes. 41-B is very long. Can you identify it more 16 specifically, subpart 1, 2-A; it goes on for four pages, 17 three pages.
18 Q Do you know whether you agree with the statement 19 generally or do you need a specific site i n the contention to 20 determine whether you agree with it or not?
21 A I need a specific.
22 MS. LETSCHE: It's on page 21.
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l THE WITNESS: I need a specific cite'in the 2 contention.
3 MS. LETSCHE: Subpart A.
4 THE WITNESS: "Only one tow truck was 5 dispatched." I am not sure. I would have to review FEMA 6 report at 37 and 65. It sounds quite reasonable to me, but 7 they may have made a mistake. I would have to look at it 8 myself.
9 BY MS. MONAGHAN:
10 Q "They" meaning whom?
11 A The authors of the contention.
73 j
(
12 Q In order to determine whether the authors of the 1
13 contention were mistaken in their statement that it would 14 have taken 30 minutes or more to remove the truck, would you 15 rely on the statements in the FEMA post-exercise assessment?
16 A No.
17 Q On what would you rely in order to test the 18 validity of the statement and the contention?
19 A Probably common sense.
20 Q Do you consider yourself an expert in assessing 21 the time it will take to remove a traffic impediment?
22 A I just said I wasn't. I just said common sense.
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.5 1 Common is different than expert.
2 Q Do you agree with the statement in contention 41-E 3 that even assuming a traffic engineer could provide 4 assistance, it would have no impact on the basic structural 5 flaws in the plan and demonstrated incapacities of LERO 6 personnel described in Contention 41-E?
7 A I am not sure, but I think so. I think it's a 8 very good point, but I would have to really investigate it 9 more.
10 Q What do you mean by "it's a very good point"? The 11 point made in the contention is a good one?
\~' 12 A- Yes, yes.
13 Q dut you are not sure about whether you agree with 14 that right now?
15 A Not yet. I would have to look at the tables of 16 the organization, the definition of the roles. It's possible 17 that putting another traffic engineer in there might so jam 18 up the communications that it would add more complexity than 19 it solves things. It's possible that they need three traffic 20 l engineers to do it. I don't know. I would have to look.
j 21 Q What is your understanding of what a traffic 22 engineer is and what his job responsibilities entail?
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1 A I don't have any at this time. I haven't' read the 2 prope3al to add a traffic engineer to the LERO personnel at 3 : EOC . I haven't seen the letter dated June 20, 1986.
4 Q Have you reviewed the portions of the LERO plan 5 that-deal with the traffic organization portion of the LERO 6 plan?
7 A I think so, but I am not certain. I have seen a-8 lot of material in the last few days and it's hard for me to 9 recall whether I have looked at that. I certainly will_look 10 at that.
11 Q Dr. Perrow, when did you begin reviewing the O
' '- material that you have reviewed to prepare yourself for the 12 13 deposition?
14 A I think I have already testified to that.
15 MS. LETSCHE: He did. Asked and answered. Tell 16 her again if you want.
17 BY MS. MONAGHAN:
18 Q Could you refresh my recollection as to when it 19 was?
20 A I would say it was early in December, probably, I 21 am not sure. But, yes, probably early in December. I 22 apologize, but I didn't think I would be asked. The date (1) l ACE-FEDERAL REPORTERS, INC.
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1 that we met in New Haven -- but it was certainly several days 2 subsequent to that.
3 Q- That's fine. General time frame is. fine. I 4 didn't expect that you would remember the precise date but 5 some people do.
6 MS. MONAGHAN: Let's go off the record a second.
7 (Whereupon, at 12:25 p.m., the deposition was 8 recessed, to be reconvened at 1:15 p.m. this same day.)
9 10 11
,, m L) 12 13 14 15 16 17 18 19 20 21 22
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1 AFTERNOON SESSION (1 :15 p.m. )
2 Whereupon, 3 CHARLES PERROW 4 resumed the stand and, having been previously duly sworn, was 5 examined and testified further as follows:
6 MS. MONAGHAN: Back on the record.
7 EXAMINATION (Continued) 8 BY MS. MONAGHAN:
9 Q Dr. Perrow, Contention 50 uses the term 10 " unanticipated and unrehearsed situation." How would you 11 define that term?
, , o
' \' You have to define it kind of negatively. That 12 A 13 is, a good part of the exercise was known ahead of time or 14 was anticipated that it would happen. Parts of it were 15 unanticipated. I see defining unanticipated as hard to do.
16 You just have to say that they were unanticipated, and parts 17 that were unrehearsed had never been rehearsed before. To my 18 knowledge they had never rehearsed with the gravel truck 19 before, so it was unrehearsed. It seems to me fairly obvious 20 as it is.
21 Q When you say that a good portion of the exercise 22 , scenario were known in advance, what do you mean by that?
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1 A There were no free-play items injected into it 2 that were not known in advance.
3 Q Do you mean by that that the players in the 4 exercise had knowledge of the specific facts of the scenario 5 before the day of the exercise?
6 A No.
7 Q Would you characterize all free-play messages as 8 unrehearsed --
9 MS. LETSCHE: Let let me characterize I am not 10 sure if Dr.~Perrow will understand the term " free-play 11 messages."
12 BY MS. MONAGHAN:
13 Q Do you understand the term?
14 A Yes. There may be a technical meaning that I am 15 not aware of, but I am thinking of the two traffic accidents, 16 the request to evacuate one school, and the rumor control 17 messages. If we call those the free-play messages, then we 18 would be clear. Now, could you ask your question again. I 19 have forgotten it already..
20 , Q Those, in fact, are examples of what constitute 21 free-play messages. To define the term " free-play messages" 22 for you, it means a message frequently in a written form that O :
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G 1 is injected into the course of the exercise which a player 2 has never seen before. He has never seen the content of the
.3 message before; and the purpose of the free-play message is 4 to spark a response from the player. The hope is that they 5 will respond appropriately to the free-play message that is 6 injected.
7 So the traffic accidents that you referred to, the 8 request to evacuate the one school -- I believe it's the 9 Ridge Elementary School that you are referring to -- and the 10 rumor control functions, are all indications of free-play 11 messages or free-play situations, q
k /
12 , A Yes.
13 Q Given the examples that you have given to me, the 14 two traffic accidents, request to evacuate the school and 15 rumor control messages as examples of free-play messages, 16 would it be your opinion that all free-play messages would 17 constitute unanticipated or unrehearsed situations?
18 A I would think so, as you have defined it, yes.
19 Q Based on your review of the FEMA exercise report, 20 is there anything else, other than a free-play message, which 21 you believe would constitute an unanticipated or unrehearsed 22 situation?
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( t-us 1 MS. LETSCHE: You are limiting this as to what be
-2 found from his review of the FEMA report?
3 BY MS. MONAGHAN:
4 Q At the present time.
5 A I suppose you would say that it was unanticipated, 6 so many errors would be made, and that had effects, and so i
7 those would be unanticipated. They were not deliberate 8 free-play messages; they were errors that were made by the 9 people who then had further consequences in the 10 organization.
11 Q Other than the FEMA exercise report, would there O,
12 be any other source that you would look to to try to 13 determine what were the unanticipated and unrehearsed 14 situations that occurred the day of the exercise?
15 A There may be other sources that would be available 16 to me, and I would use them, but I don't know of them yet.
17 So I really can't say. I would love to find more.
18 Q Find more sources or more unanticipated and 19 unrehearsed situations? )
20 A More sources.
21 Q Now, Dr. Perrow, is it your opinion that the LERO 22 personnel responded -- strike that.
(
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's 1 Is it your opinion that the LILCO training program 2 has not successfully trained LERO personnel to respond to 3 unanticipated and unrehearsed situations?
4 A Yes.
5 Q On what do you base that opinion?
6 A on their performance during the exercise.
7 Q What specific aspects of their performance during 8 the exercise do you rely upon for your opinion?
9 A What specific aspects of their performance? I j 10 would consider virtually all aspects of the exercise.
11 Problems showed up in most places. We have been talking i
'- Was there something else you wanted to --
12 about them.
13 Q I am trying to determine which specific incidents 14 that occurred during the exercise you are relying on for your 15 opinion that LERO personnel were unable to respond to 16 unanticipated and unrehearsed situations, and that's what my 17 question goes to.
18 A I haven't reviewed all the stuff, so I couldn't 19 possibly give you the full thing. I am going to look very 20 carefully. If there are other documents other than FEMA 21 documents that could give me more information, such as those 22 that reduce the information on the rumor control things, I (o>
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1 would use those and go into that, but I don't even know if 2 that stuff exists. But the rumor control thing is something 3 that doesn't appear in the FEMA document but was 4 independently developed.
5 Q Do you know about the rumor control thing?
6 A It's in one of the depositions -- I mean, one et 7 -the contentions.
8 Q So your knowledge of what you consider 9 unanticipated and unrehearsed situations to which the LILCO 10 personnel responded improperly is based on your review of the 11 contentions and on your review of the FEMA report; is that
(~#)
'- 12 correct?
13 A Yes.
14 Q That is all that you have reviewed that you can 15 rely upon for that opinion?
16 A Yes.
17 Q Would it be possible that your opinion might be 18 changed in some way by reviewing additional documents that 19 might be made available to you?
20 A Absolutely.
21 Q Would you identify for me -- strike that.
22 First of all, is it your opinion that LILCO's n
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-29296.0 cox 127 U-1 training program has been ineffective in instructing LERO
- 2. personnel to follow and implement the procedures?
3 A It appears so.
4 Q Can you identify for me the factual events on 5 which you rely for that opinion?
6 A Well, that's the same answer again. We have all 7 the evidence that FEMA has provided of failures in the 8 exercise. Some of those are linked not to training but to 9 hardware problems or other kinds of problems, but many are 10 linked to training problems. And then there is evidence that 11 counsel developed independently of the FEMA report that we
,a
! I
'# 12 were just talking about, and I guess I don't know how to 13 answer, because the contentions were full of it.
14 Q So basically you were relying on the substance of 15 the other contentions which you have read and the substance 16 of the other contentions for your opinion?
3 17 A That's what I just testified to. I believe I just 18 said that a minute ago.
19 Q Dr. Perrow, is it your opinion that the LERO 20 training program has not effectively trained personnel to 21 communicate necessary and sufficient data and information?
22 A Yes, s")
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.1 Q Would you identify for me the facts on which you 2 rely for your opinion?
3 A The traffic accidents, again, rumor control 4 center, the EBS broadcasts that have the wrong information in 5 them and so on.
6 Q Are there any other facts --
7 A There may be, but I haven't dug them out yet. I 8 haven't done them systematically.
9 Q So at the present time your opinion is based upon 10 traffic accidents, rumor control and EBS broadcasts?
11 A I would be willing to go along with that because I i
\ )
-12 haven't read everything.
13 Q Is it your opinion that the training program does 14 not effectively train LERO personnel to effectively follow 15 directions given by LERO superiors in an emergency?
16 A Yes. Now I am trying to think of the particular 17 -- well, they didn't read their dosimeter badges at the 18 proper time. They didn't go to the right garages. They took 19 shortcuts in their -- the bus drivers in tours. Those are 20 l three of several other -- I think of several examples that i
21 h would support that contention.
22 Q When you said they took shortcuts in tours, what (1)
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1 do you mean by that?
2 A When they were to go through the neighborhood'and 3 pick.up people, they didn't follow the prescribed route.
4 They didn't follow orders.' Here is the route, here is the 5 order, you follow it. They didn't do it.
6 Q Just so I am clear, the documents that you are 7 relying on fir your opinion are the FEMA report and the. text 8 of the contentions. Is there anything else on which you are 9 relying for your opinion that the LER0' personnel were not 10 effectively trained to follow directions given by superiors 11 during emergency?
-\(D
12 A No.
13 Q No, there are no other documents?
14 A Are there cther documents? I wonder why you keep 15 asking this.
16 Q There are quite a few documents, Dr. Perrow.
17 A Could I ask what they are?
18 Q I suggest that you address that question.to your 19 counsel.
20 A Okay, all right.
21 Q in your opinion, has the LILCO training program i 22 effectively trained LERO personnel to exercise independent (2) i ACE-FEDERAL REPORTERS, INC.
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29296.0 cox' 130 1 judgment in dealing with situations presented.during an 2 emergency?
3 A No, it is not.
4 Q Please identify for me the fac on which you rely 5- for that opinion.
6 A The traffic control. Same cases again keep coming 7 up. With the simulated accidents, FEMA specifically targets 8 this area in one or two places. I don't recall them directly 9 now at the top of my head what FEMA does, but I think it 10 specifically refers to what you are referring to. I don't 11 recall directly. I will have to do more systematic work.
("h
\' 12 But I have seen enough to suggest that there is evidence for 13 the contention.
14 Q What you have reviewed which supports your opinion 15 are the contentions themselves and the FEMA report; is that 16 correct?
17 A Once again, yes.
18 Q I just want to be sure that I understand the basis 19 for your opinions, Dr. Perrow.
20 A I don't know anything else, but you can keep 21 asking me.
22 Q Is it your opinion that the LILCO training program n-ACE-FEDERAL REPORTERS, INC.
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1 does not effectively use LERO personnel to deal with common 2 sense in situations presented in an emergency?
3 A Yes. I would just have one qualification to that 4 contention. I don't know how you train people to do that, 5 but if through the -- that's difficult, but training has not 6 evidently produced common sense in these cases, because there 7 are some cases where common sense was not used.
8 Q- You indicated that there were some cases where 9 common sense was not used. Based on your review of the FEMA 10 exercise report, does the lack of common sense appear to be a 11 pervasive problem on the day of the exercise?
a r')
\~ 12 A Hard for me to say that.
13 Q Why is it difficult for you to make that 14 assessment?
15 A Because I don't really have a good sampling of all 16 the behavior. There are many instances of lack of common 17 sense. Whether it's a pervasive problem or not I am just not 10 prepared to say.
19 Q Do you think you will be in a better position to 20 make that assessment if you have reviewed additional 21 documents?
22 A Yes.
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- N._3) 1- Q Let's say, for example, that you had reviewed the 2 documents that were generated by the LILCO players on the' day 3 of the exercise, which include logs and message forms. Would 4 that assist you in making your assessment?
5 A It might. -I would have to look at those. I am 6 not sure.
7 Q Would a review of the critique forms generated by.
8 the FEMA controllers assist you in making an assessment as to 9 whether the lack of common sense was a pervasive problem on 10 the day of the exercise?
11 A It might, but, you know, maybe that's already been
(~T
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12 done sufficiently by counsel, so that if I reviewed those, I 13 would come to the conclusion that no additional information 14 was provided. On the other hand, it might. I don't know. I 15 haven't even seen one of those, so I don't even know what 16 they look like.
17 MS. LETSCHE: Nobody has, Dr. Perrow. Don't feel 18 alone in that. Counsel hasn't seen them either.
19 BY MS. MONAGHAN:
20 Q Counsel has seen one of them and seen the forms i
21 l themselves but without the benefit of the evaluator's 22 comments.
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1 A Could I request that I be provided access to 2- those?
~3 MS. MONAGHAN: Off off the record, please. ,
4 (Discussion off the record.)
5 MS. MONAGHAN: Back on the record.
4 6 BY MS. MONAGHAN:
7 Q Is it your opinion that the LILCO training program 8 has not effectively trained LERO personnel to provide timely, 9 accurate and nonconflicting information to the public through 10 the media during an emergency?
11 A Yes.
p
\- 12 Q Would you please state for me the facts on which 13 you rely for your opinion?
t 14 A They are cited in the contention. The messages 15 were incomplete, sometimes inaccurate; they were late. They 16 were inaccurate. I said that. There are many cases on which 17 the contentions lay out that information.
18 Q Could you point me to the specific portion of the i
- 19 contentions which you are relying on for that?
20 ! A It might take me some time, but, for example, if 21 ; maybe this would be sufficient, for example, the EBS that i
22 went out every 15 minutes and sent back, evacuation -- yes, l
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1 the broadcaster said that buses would come by every 15 2 minutes to pick up people who didn't have transportation.
3 Those buses were not there, not mobilized; couldn't possibly 4 be happening. That, to me, is inaccurate. An inaccuracy in 5 their broadcast and must have something to do with training, 6 because they were trained to do this. There is no reason why 7 they should make that kind of an error.
8 Q If you would like to review any of the contentions 9 prior to giving an answer, you are certainly welcome to do 10 that. I would encourage you to do that if it's going to 11 assist you in providing a more complete answer.
-O 12 A I will do that, yes.
13 Q Let's look at Contention 50-F, which deals with 14 the provision of timely, accurate and consistent 15 information.
16 A We were just talking about that.
17 Q Now, that contention cross-references a number of 18 other contentions and cross-references some conclusions in
,19 the FEMA exercise assessment.
20 i A Yes.
21 Q Are those the contentions on which you are relying 22 for your facts?
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Q.)
1 A Yes.
2 Q Do you know whether you rely on those contentions 3 in their entirety?
4 A I am sorry, what do you mean?
5 Q Well, the contentions have a number of subparts, 6 as you are aware.
7 A Contention Number 40-C, do I rely upon everything 8 in Contention 407 9 Q Well, when it stipulates 40-C, I assume you are 10 only relying on 40-c.
40-C, sub 1. \
11 A On
\' 12 Q It says here Contention 37. Are you relying on 4
13 Contention 37 in its entirety?
14 A Yes.
15 0 You were relying on Contention 38 in its entirety?
16 A Yes.
17 Q Would you look at Contention 38 sub D, which 18 I appears on page 100 of the contentions of the August 1 format 19 of the contentions?
20 , A Page 100?
i 21 .
Q Yes.
22 A D?
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1 Q D as in dog.
2 A Oh, yes, " copying machines."
3 Q Is that one of the facts on which you rely for 4 your opinion that the training program has not effectively 5 trained LERO personnel to provide timely, accurate, 6 consistent and nonconflicting information to the public?
7 A Not necessarily. As I indicated, I distinguished 7 8 training from hardware problems. However, good training 9 anticipates hardware problems. So good training always has
, 10 backups, redundancies, alternative ways of handling things.
11 So if the copying machine breaks down, as it breaks down, a
12 good training problem. The problem is not with -- the
- 13 training program did not cause the copying machine to break 14 down; but the copying machine breaking down, the hardware 15 problem, requires, since that's always possible, requires 16 that training people handle these contingencies. I saw no 17 evidence from the rather limited description of this event
, 18 that I hat from FEMA and the contention that there was 1
19 l anything a,n the training program that trained people to get
> l 20 i around that barrier.
21 ! Q Dr. Perrow, are you using the specific incident of 22 the failure of the copying machine to support your opinion (1) '
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LJ l that the training program didn't train LERO personnel to 2 provide timely and accurate information?
3 A I might. It's not the only one, I assure you, but 4 I might use that as an example of the case.
5 Q What about Contention 38-E, which appears just 6 below the one we were just discussing? Are you going to use 7 that factual circumstance to support your opinion?
8 A Absolutely. I mean, that is so easy, so 9 ridiculous. That's such a low hurdle to jump over, to have 10 an adequate map.
11 Q You are t sing that, as I understand it, to support O
\J 12 your opinion that tne training program has not effectively 13 trained personnel t,o provide timely, accurate, consistent and 14 nonconflicting information; is that correct?
15 A Right. All three years of it. All three years of
~
W*t" IN AUd GUAl 0 16 the training program, they went along w+ thin-adequate maps .
l 17 Q Is it your opinion that LILCO has failed to 18 f provide training to persons and organizations relied on for 19 g implenentation of the plan?
20 k A Oh, yes.
g 21 ! Q What facts do you rely on for that opinion?
22 h A As stated in contentions, they literally have not i
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I V) 1 provided the training. They did not go out and train these 2 people.
3 Q Which personnel were not trained?
4 A I would have to look at the contention to be 5 specific on that. I do not remember or recall which one.
6 Q The specific contention to which we are referring 7 is Contention 50-G.
8 A on page?
9 Q 161.
10 A Let me know when you change contentions, would 11 you. That's a big jump. Contention G. Oh, yes, back to 12 50. That actually is described in Contentions 27 and 28.
13 Could we go to that?
14 Q If that will help you, we certainly can.
15 MS. LETSCHE: Page 01 and 82.
16 THE WITNESS: "No training of school bus drivers."
17 Gehool bus drivers had no training in dosimetry, use of i
10 potassium iodide, et cetera. There were others though.
19 l Ambulance drivers are not trained in excessive exposure ;
i 20 i oper ation procedures and so on. Is that what you meant?
l
- 21 ! BY MS. MONAGHAN:
I Q What I am trying to determine, Dr. Perrow, is that 22 l (1) i I ACE-FEDERAL REPORTERS, INC.
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V 1 what you mean?
2 A Yes. Those are examples.
3 Q In giving your opinion with respect to contention 4 50-G.
5 A (Witness nodded head.)
6 Q Are those the only examples on which you will 7 rely?
8 A No.
9 Q Can you enumerate for me any other factual ,
10 examples on which you intend to rely to support your 11 opinion?
O
'# 12 A Not at this time, but I am sure I will when I do 13 my testimony, because I don't recall specifically in 14 contention -- in connection with that part of Contention 50, 15 0 Contention 50-0 references only Contentions 27 and 16 28 and no other contentions; is that correct?
17 A Yes. I think that's probably an error. I think 18 there are other places in there that show that they did not 19 i provide training to persons and organizations that they 20 relied upon. I think that can be expanded.
, 21 l Q But at this time you are not able to identify any 22 additional persons or organizations which were not trained?
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'w.J 1 A , Right.
2 Q Do you expect that you would find that information 3 in the FEMA report?
4 A No.
S Q What additional information would you need in 6 order to be able to determine whether there were other
, 7 organizations or persons who did not receive training?
8 A Call them up.
9 Q How would you go about determining which 10 organizations and persons to contact to determine whether 4
11 they had received training?
O 12 A They are listed by LILCO.
13 Q Where are those organizations listed?
14 A In the plan.
15 Q Is it your opinion that LERO training is deficient 16 in the area of dosimetry?
17 A Yes.
18 Q Let me just be sure. Do you understand what I 19 mean when I use the term " dosimetry"?
20 A Yes.
21 Q Would you state the facts for me on which you rely 22 I for your opinion that the training program was deficient in (2) i ACE-FEDERAL REPORTERS, INC.
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2 A Bus drivers failed to check their dosimeters.
3 They were also unclear about radiation exposures and 4 authority with regard to -- well, that's not related to 5 dosimetry. That's another problem; so just those two.
6 Q So the authority you say is not related to the 7 donimetry but how frequently to check the dosimetry?
8 A Yes.
9 Q Exposure levels; was that the other thing you 10 said?
j 11 A Yes.
O 12 Q Other than the bus drivers --
13 A Traffic guides.
14 Q Now, Contention 50-H cross-references contentions 15 42 and 45. Do you know whether you will be relying on all 16 portions of Contention 42?
l 17 A Can I just review this for a second now?
18 Q Certainly, take your time.
19 A I would expect so, but I would have to examine 42 1
20 to give you a definitive answer. It really can't be a l 21 definitive answer, because, in part, I haven't developed my 22 I argument, so I am not sure what I want to use. !
l
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29296.0 cox 142 1 MS. LETSCHE: It's on page 123, 2 THE WITNESS: 123, but I don't remember these by 3 numbers, so let me see if I am familiar with that. Whether I 4 was struck by it. Oh, yes. I think the answer to that would 5 be yes.
6 BY MS. MONAGHAN:
i 7 Q You are going to rely on Contention 42-A with 8 respect to the insertion of the two free-play road impediment 9 messages with respect to deficiency and dosimetry?
10 A Yes.
11 Q Yes?
CE) 12 A Yes.
13 Q What about 42-B with recpect to a free-play
- 14 message requesting a bus to assist in the-evacuation of
, 15 children from the Ridge Elementary School. You are going to 16 rely on that for your opinion with respect to dosimetry?
17 A With respect to dosimetry, no. Not necessarily 18 dosimetry.
19 ,
Q That's what we are discussing right now, what you l
20 l are going to rely on for your opinion about the dosimetry, i
21 because 50-H cross-references 42 and 45.
22 MS. LETSCHE: 50-H also refers to other things (2) l i
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29296.0 cox 143 1 other than dosimetry: Exposure control, potassium iodide, 2 understanding of radiation terminology, as well as dosimetry.
3 BY MS. MONAGHAN:
4 Q Dr. Perrow, I think Ms. Letsche is correct in that 5 it is a little broader than just dosimetry. Look at all the 6 terms. Can you do that? I understand -- correct me, if I am 1
7 wrong -- that your opinion is that the LERO opinion was 8 deficient in all of the areas; is that correct?
9 A Yes, I think B is relevant.
10 Q You think B is relevant to that?
11 A Yes.
LO l
12 Q Let's look at C. Is 42-C relevant to that?
13 A Yes.
14 Q You would rely on that with the opinion that you 15 have just given that the opinion is deficient in all of those 16 areas?
17 A Yes.
i 18 Q ilow about 42 -D.
19 A Well, it certainly talks about deficiencies, but I 20 l whether or not they are specifically related to contentions l
21 i raised in 50-H, I don't know. I don't think so, but I would 22 reserve judgment on that. You would have to give me a few O l ACE-FEDERAL REPORTERS, INC.
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1 minutes to really think that through.
2 Q Would you like to take a few minutes right now to 3 take a look at that and be sure that you have read all the 4 parts of 42-D?
5 A I am really wondering why this is being asked.
6 So could I confer with you for a minute?
7 MS. LETSCHE: Sure.
8 MS. MONAGHAN: Let the record reflect that the 9 witness conferred with counsel.
10 THE WITNESS: Yes, there was an item in there I 11 had forgotten about. Yes, I would rely upon this 12 authorization of exposures in excess to the general public, 13 P-A-G small S is referred to and that is relevant. Sorry.
.)
14 BY MS. MONAGHAN:
15 Q Would it just be that specific incidence in 42, 16 point D?
17 A I don't know, but that's enough to say that that l
10 brings -- you asked about D.
19 Q Yes.
20 A Now do you want me to go through it line by line?
21 Q Let me just ask you a question, Dr. Perrow. Are
, 22 you relying, for example, cited in 42-D that the one traffic
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29296.0 cox 145 1 guide, only one traffic guide knew of the location of the 2 Nassau Coliseum reception center, to support your opinion 3 that training in the areas of dosimetry control, et cetera, 4 was insufficient?
5 A No. ;
6 0 Let's look at 42-E. ,
7 A Yes.
8 Q It's the same question, your opinion on dosimetry 9 exposure control, et cetera.
10 A I love that paragraph. No, that is not. That's 11 relevant to a lot of other things but but not to dosimetry.
l 12 Q What about F?
13 A No.
14 Q Just so I am sure we are getting a clearance on l
15 the record, when you say it's not related to dosimetry, you 16 mean dosimetry and the other things that are listed in 50-H; 17 in that correct?
10 A Exposure control, I understand the terminology.
19 Q What about 0, it you would just look at that, i
l 20 42-0.
I I 21 l A I think that is relevant because in contention 38 I
l 22 it deals with information about expocures, control, and that s
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[} l 1 is quite relevant.
2 Q Would you turn to contention 45, which begins at 3 page 136. Again, it's the same question as to whether or not 4 you are relying on specific incidents of each of the subparts
. 5 in order to support your opinion that the LILCO training 6 program was ceficient in the areas of dosimetry and related 7 areas as listed in contention 50-A.
8 A We are dealing with 45-A first?
. 9 Q Please. A has a number of subparts of A. If you 10 want to deal with the individual subparts separately, that's 11 fine.
3 12 A Let me read it. This is not one I am familiar 13 with, I think.
I
! 14 A A seems to be no. Do you want me to go on to D?
15 Q Please.
16 A Well, B, I think, is probably relevant because it 17 you don't get people out of the path of the plume, you have
! 10 failed in the exposure control, no I would use that. C.
19 Docan't seem to be relevant. D, yes. That is relevant.
20 Dose assessment status barred and perhaps other items. E, 21 oh, yes. No.
Q I am sorry, Dr. Perrow, was your oh yes, that oh 22 l
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29296.0 cox 147 (Gi 1 yes, you recognized having read part E, or that you were 2 going to rely on it?
3 A No, remember that story, delightful, but the 4 answer to E is no.
S Q No, you will not rely on it?
6 A Not for support of 50-H.
7 Q of this particular opinion?
0 A Yes.
l 9 A P, I would rely upon, brings in the rumor control t-10 center. O, I would rely upon, particularly O sub 3, III.
11 Q Is that the only part of G you will rely upon?
O 12 A That's what I have got 80 far. Yes. r 13 Q So with respect to 42 -- 45-0, rather, you will 14 rely, you believe, only on subpart 3 to support your opinion
, 15 that the training and dosimetry in related areas was
) 16 incorrect?
17 A No. I didn't say that. I said I would report on la F, 0, subpart 3.
1 19 ! Q I am norry, I wasn't limiting you, Dr. Pet row, I l
20 ! wasn't limiting you just to subpart O. I am only trying to :
21 i define within a which nubparts of a you are relying on.
22 A Excuse me. Yes. Only that part, as far as I know i ($)
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.cox 140 1 now. Let me explain that if I found out in further 2 examination of traffic point coordinators's inability to 3 , follow instructions created a problem for a traffic guide or, 4 that is somebody below this person or somebody above them 5 that then spilled over into a problem of exposure control, I t 6 would like to warn you that I would bring in G-4 freely or 7 any other part. That is, I am only identifying the parts 0 that are directly related to this now. ,
9 In my experience, in studying organizations, that 10 is the tip of the iceberg; and I think we have a large and 11 cold iceberg here.
O 12 I expect that to find by tying things together we ,
13 will find many connections, so that I could say this 14 particular paragraph certainly relates to understanding of 15 radiation terminology, even though it doesn't mention it.
16 Decauno it impacts upon another part which impacts upon i 17 another part. Organizations are, you know, linked together
! f i la in sometimes obscure ways.
1 l 19 So the fact that it is not mentioned in any i l
20 , paragraph doodn't mean that I won't une it, so I just wanted ,
21 to warn you. !
22 Q Will you une it to show that the training program l l 1
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1 was deficient?
2 A Sure.
3 Q Let's take this very specific example that you are 4 using here. The training program was deficient in donimetry S exposure control and related areas?
6 A Yes.
7 Q Even though the problems that you may identify e
O with the traffic point coordinator might deal far more with {'
i 9 his ability to dispatch buses, but that that might, in turn, t
) 10 have an effect on the exposure limits to which particular i !
11 traffic person was exposed?
{
1 O 12 A Yes. I think his ability to dispatch busen is i
13 related to training, and the dispatching is related to 14 radiation problems. So, yes, there would be a connection.
1 15 You started your statement by saying "even though." I would
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16 a ny i t 's not a ca s e o f ym-44Wt -know . It's because.
17 Q Would it matter to you how far removed from the ,
10 initial incident, for example, if the initial incident was a 7,
19 bus dispatch problem, would it matter to you how far down the i 20 organizational chain the pressure control problem arose for ,
I 21 f you to link the initial incident with the final incident?
J 22 A No.
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U So, therefore, no matter how far removed the two 1 Q i
2 were from one another, you would still use the initial i 3 dispatch incident as evidence of a problem with the training 4 program with respect to dosimetry exposure control and 5 related arean; is that correct?
6 MS. LETSClit Let me just object. I think you are 7 mischaracterizing what Dr. Perrow stated. This whole line of 8 questioning began with his statement to you that it is 9 possible, if after he reviews more documento, he were to find 10 something with regard to the traffic control coordinator that 11 he felt was linked, he might go ahead and use it and he ,
12 wanted to warn you of that fact. I don't think he should ,
! 13 charactorize his testimony an saying he would or would not do 1
14 any of those things. I think he was telling you what he may ,
15 do on down the road.
i 16 MG. MON AGil AN : I think Dr. Perrow and I were 17 discussing a hypothetical situation, no I can understand what 18 the parametern might be of his testimony which he might give i l i
19 ( later depending upon facto he might discover.
i 5
l 20 l Tilt WITNEGS: Let me give you an example, if I 21 may. We once studied an organization which had onormous l ,
! 22 conflictu between nales and production at the highest level i
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cox 151 0 1 in the organization. They were trying to work on it on the i l 2 basis of the personalities and the authority structure of !
3 those types of people.
4 After a lot of work and digging, we went down f 5 several levels into that organization, until we came to a 6 clerk that was sitting literally in a little room off a floor
- f 7 that made steel, it was a specialty firm, that made steels, i
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4 O sitting in a little room and making decisions about ;
4 2 9 production that had an enormous impact upon sales, and
) 10 because it was in production side, production thought that i
i 11 clerk was in their hands. But we found out that sales was i
!O 12 entertaining and buttering up that clerk and getting the I 13 clerk to view things in quite a different way. !
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14 11 0 , now, here is my point. The actions of a few ,
4 i 15 salesmen, they weren't even salesmen, they were product !
i i 16 speciallots, way down in the organization, had an impact upon i 1
! 17 a clerk who made decisionn which are of seemingly marginal
! i
) 10 importance in that organization, which then threaded their '
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19 way all the way up to the top to create a first-clarrs l 20 conflict at the top of that organization. ;
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! 21 ! tio the remoteness that you npoke of in your t ;
22 question to me is something that would not bother me. I !
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29296.0 cox 152 0 1 might find, because of my experience with organizations, I 2 might find in this organization such a series of connections 3 that one would not anticipate.
4 BY M3. MON AGil AN :
5 Q Dr. Perrow, is it your opinion that LILCO's 6 proposals to modify the training, materials or procedures, 7 would not correct the flaws revealed by the exercise?
0 A Yeo.
9 0 What do you base that opinion on?
10 A They have had three yearn doing thin. They do a 11 lot of training and the performance was so poor that I O 12 aantme, that we must annume that there la nomething more 13 basic there than a failure to get in a better brochure, a 14 better videotape, a better whatever eine you are going to do 15 to improve the training program.
16 Q Do you know what LILCO proposes to do to fix the 17 training program procedures?
10 A No.
19 Q llave you reviewed the training materials which are f 20 currently being used in the LILCO training program?
l 21 A No. We covered that before.
l 1 22 l 0 tio your review of the LILCO training program is i
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1 limited to what you have read in the plant procedures; is i 2 that right?
3 A Yes.
4 Q Is it your opinion then that the personnel in the 5 LERO organization are not trainable?
6 A No.
7 Q Is it your opinion then that the LERO training 0 program cannot be fixed to take care of the problems that 9 were revealed on the day of the exercise?
10 MS. LETScilE Dr. Perrow has already said he 11 hann't had an opportunity yet to review the training O 12 materials or review the proposed changen to the training j 13 materials. I am not sure how you could expect him to be in a ;
14 position to annwor that question.
15 BY MS. MONAGil AN :
16 Q Dr. Perrow, are you able to answer that question? ,
17 A No. What she said is absolutely true. I am not 10 optimistic, given that they have done over three yearn, under 19 very good conditions, all that training. I am not optimistic 20 that a fix would work. Ilowever, I haven't neon what a fix 21 l in. Go how could I possibly testify that their f1x would or l 22 ! would not work?
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V 1 Q Uut you just told me that it was your opinion that 2 LILCO's proposals to modify the training materials or 3 procedures would not correct the flaws revealed by the 4 exercise; is that true?
5 A That's true, could you read back my answer to 6 that question.
7 MS. MON A0ll AN : Please go ahead and repeat his 8 answer to the question. I think he would like to repeat his 9 answer as to what exactly that he said, k
10 (The reporter read the record as requested.)
11 DY MS. MON AGil AN :
O 12 Q We are back on the record, 13 A I would like to amend the answer to the question 14 that you referred to, and say I don't think it's going to 15 correct the problem for the reasons I gave them. But it is 16 always possible that the letter which I have not soon from 17 John Leonard to liarold Denson has such a stunning proposal 10 Cor a new training program that it could be corrected. I l '> have not soon that. I am not optimistic, but it in 20 possible. Go in that sense I probably -- I cannot say that I i
21 ) could agree to Contention I becauan I haven't seen the letter 22 on which it is based.
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29296.0 cox 155 1 Q Is it your testimony, then, Dr. Perrow, that you 2 have insufficient information at this time about which to 3 render an opinion in contention 50-I?
4 A No. 50-I, yes.
5 Q I think that's the one we were just referring to.
6 A Yes.
7 Q Dr. Perrow, would you look back again at 0 Contention 50-A which appears at 159.
1 9 A Yes.
10 0 We discussed earlier the unanticipated and 11 unrohearned situation, and you gave your opinion that the O 12 exercise demonstrated that the LE110 training program was 13 unsuccessful in training its people to respond to unrohearsed 14 and unanticipated situations, and at that time you listed for 15 me a number of instances which you believed characterized 1
1C unanticipated or unrehearned situations, including the two 17 traffic incidents, the request to evacuate the Itidge 10 l'lementary School and the rumor control aspects, i
A liight.
19 l 20 I Q I would ask you at this time to look at the 1
21 j contentions that are cross-referenced in contention 50-A and 22 l Int me know if you are relying on those contentions in their C:) l .
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29296.0 cox 156 1 entirety or only on certain parts of the contentions. I 2 believe that the contentions cross-referenced are 38, 39, 41 3 and 42.
4 A Let me understand now. You want me to go through 5 the entire 38 contention, entire 39, entire 41 and 42, which 6 I have testified that I agree with, and specify which parts 7 of those contentions or the whole of those contentions, O relates to the statement in 50-A?
9 Q That's correct.
10 A I don't know if I can do it if we are going to 11 close by 2:30. It is now 2:20, but I will certainly try.
12 Now, does anybody have the number of 38?
13 MS. LETSCHE: It starts on page 97. Let me just 14 note my objection for the record. You already have an answer 15 from this witness, Ms. Monaghan, about Contention 50, subpart 16 A. I believe you already asked him whether he intends to i 17 rely upon the contentions that are cross-referenced in there,
! and I believe Dr. Perrow stated at the beginning of his 10 l
19 ' answers to your question concerning contention 50 that he had 20 not completed his review of the things referenced in these I
1 21 contentions.
22 Co, frankly, I think it's sort of a waste of time
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1 to have him sit here and read every single-one of these 2 contentions when we already have a statement as to what he 3 may use. You are not going to get any more than that by 4 having him sit here and read through them and say it again 5 with respect to the particular contentions. If you want to 6 take up another 10 minutes of time doing that, I won't stop 7 you.
8 BY MS. MONAGHAN:
, 9 Q Proceed.
, 10 A Okay. We are dealing with Contention 38-A. Is 11 that okay?
- ( 12 Q That's fine.
13 A This is unanticipated or unrehearsed situations, 14 okay.
15 Q Were the events, facts described in Contention 16 30-A are events and facts that you are going to rely on the 17 opinion that the LILCO training program has not effectively 18 f or appropriately trained its personnel to respond to i
- 19 unanticipated or unrehearsed situations. I think that is the 20 I intention of Contention 50-A.
l 21 A All right. Could I say with reference --
i 22 Q Go ahead.
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-V 1 A Could I say with reference to A that I cannot 2 answer at this time because I may be able to get data 3 regarding the delay of the first press briefing, which would 4 indicate that there was an unanticipated or unrehearsed 5 situation in connection with that release which would thus 6 make this an appropriate point to take up.
7 Q Based on the statements currently made in 8 Contention 38-A, is your assessment that you will or will not 9 use it if the sum total of the facts available are what are 10 currently listed -
11 A 1 already answered.
O 12 MS. LETSCHE: I think he said sitting here today-t I 13 he can't say that.
14 BY MS. MONAGHAN:
15 Q Let's move on to 38-B.
i 16 A I think that will be a fairly consistent response, 17 but let's try. Oh, news release. With regard to B, I don't 4
18 ! know at this time why the first LERO press release did not 19 contain up-to-date information and was inaccurate. But I I
20 j would like to pursue the matter and find out if that was due 21 j to the fact that the LILCO personnel could not respond l
22 ! properly to unanticipated or unrehearsed situations, which O
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v 1 may have been the reason why the press release was so inept.
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2 Q 38-C.
3 A Regarding 38-C, I do not know at the present time 4 why the director did not approve of the message until 9:00, 5 and that it was not distributed as of 9:15, a delay of almost 6 one hour, but it seems to me quite possibly the reason for 7 that delay was the fact that LERO people, personnel, were not 8 effectively trained to deal with unanticipated and 9 unrehearsed situations. Shall I go on to D?
10 Q Please do. Yes, please go on.
11 A You are serious?
() 12 Q Yes. Quite serious.
13 A All right. Insufficient copying capabilities -- I 14 certainly would include D.
15 Q You would include D?
16 A Yes, I would include E. I do not know about F.
17 I would have to find more information about the source of l
18 ! that problem; is that sufficient?
l 19 Q That's fine.
20 A Well, then we can go through fast. G. I do not 21 know why the press releases were distributed till much too 22 late, but it might have had something to do with ability to lO l
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I respond to unanticipated and unrehearsed situations. H, I 2 don't know about H. Might. I, probably not. That sounds 3 more like deliberate actions rather than inadvertent 4 actions. However, further investigation might reveal it's 5 not deliberate, was inadvertent and was due to inability to 6 respond to unanticipated and unrehearsed situations that are 7 likely to arise in an emergency.
8 J, it is very likely that J is the result of what 9 I have been talking about, and I would like to pursue it in 10 my research; and thus it might be used. The same answer can 11 be applied to K. L is clearly a case of the inabilities to
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12 I i
respond to unanticipated and unrehearsed situations. So is 13 M, it appears, and N, as in " nanny." I do not know why O 14 occurred, but I might in my research find that it was due to l
15 l the inability to respond to unanticipated and unrehearsed 1
situations likely to arise in an emergency.
16 l I
17 l I am not sure about P. It is such a general 18 charge. Q is not relevant, as you can clearly see. That 19 concludes 38.
20 )
Q Would you look at 39 with the same question in i
21 mind?
22 MS. LETSCHE: No, I think at this point, n,.a ACE-FEDERAL REPORTERS, INC.
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29296.0 cox 161 uJ 1 Ms. Monaghan, it's a little after 2:30. If you wish to ask 2 any concluding questions of Dr. Perrow, feel free to do 3 that. You have the answers to your general questions 4 concerning what he intends to rely upon with respect to his 5 testimony on Contention 50. He has told you that he intends 6 to do more analysis,'that he may use matters referenced in 7 the contentions in the FEMA report citations that are set 8 forth in Contention 50 and that based upon further analysis 9 he may use additional things or not.
10 As I said, if you have some summarizing questions 11 you wish to ask him, go right ahead. But I think this is a
\
'/ 12 clear waste of everyone's time, most particularly 13 Dr. Perrow's, to have him sit through here and read through 14 every subpart saying I might use this one or I might not when 15 he has told you generally what his opinions are concerning 16 the use of each of those cross-reference.
17 MS. MONAGHAN: As you know, Ms. Letsche, I am 18 entitled to know under the rules of practice to understand 19 the facts on which Dr. Perrow is going to base his opinion, 20 and the purpose of this exercise this afternoon has been to 21 ! try to determine what the facts are on which he is going to I
22 base his opinion. He has stated that he has reviewed the l
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v 1 FEMA report and contentions and views in relying on the facts 2 and contentions in the FEMA report. The purpose of this is 3 to try to assist him in what specific facts he is going to 4 rely.on in order to support the opinions that he has stated 5 he is going to give, to assist his recollection.
6 BY MS. MONAGHAN:
7 Q I would like to continue, Dr. Perrow, with 8 Contention 39 so I can know whether or not he intends to rely 9 on the specific facts delineated in that opinion to support 10 his contention in 50-A.
11 MS. LETSCHE: Why don't you ask Dr. Perrow if he
'# 12 intends to rely upon the facts in Contention 39.
13 MS. MONAGHAN: That's the question I thought we 14 were pursuing.
15 MS. LETSCHE: You may answer.
16 THE WITNESS: I intend to rely upon them in 17 connection with a number of contentions with a lot of 18 information that is presented there.
19 BY MS, MONAGHAN:
20 Q Do you intend to rely on the facts outlined in 21 Contention 39 for your opinion that the exercise demonstrated 22 , that the LILCO program has not successfully trained personnel i
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29296.0 cox 163 0;~x 1 to respond to unanticipated and unrehearsed situations?
2 MS. LETSCHE: Dr. Perrow has already stated he 3 does intend to rely on rumor control information and events 4 during the exercise in support of his opinion on Contention 5 50 subpart A. That was about an hour and a half ago that he 6 made that statement.
7 BY MS. MONAGHAN:
8 Q Dr. Perrow, do you intend to rely on that?
9 A Yes.
10 Q You intend to rely on all the subparts of 11 Contention 39?
(~)%
12 A I did not say that.
13 Q Do you intend to rely on all the subparts of 14 Contention 39 to support your opinion?
15 A I do not know at this time, because I have not 16 done the work yet. I cannot -- it's hard for me to say 17 whether I am going to rely on subpart this or that. Chances b
18 I are that some of them are clearly relevant, as is obvious.
19 Some are clearly irrelevant, as was obvious, like G of the 20 ! previous one. Some of them are ambiguous. I haven't decided 21 l yet.
i 1
22 i I am always prepared to find some trail, like I O ,
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1 was describing, in this organization that will lead me to a 1 2 subpart of some contention that I never anticipated that I 3 would rely upon. That is always a possibility. One general 4 thing I could say is that there is a chance that I will rely 5 on any one of these.
6 Q Dr. Perrow, I would ask you to look at Contention 7 50-A with me.
8 A Yes.
9 Q Would you tell me whether the answer that you have 10 just given with respect to Contention 39, and your intention 11 to use Contention 39 and its subparts, would be the same for
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12 Contention 41 and Contention 42, each of which are 13 cross-referenced in Contention 50-A.
14 A Yes.
15 Q Would you look at Contention 50-B.
16 A 50-B, I don't recall. I am sorry, yes. That's 17 the next one.
18 Q Now, again, 50-B cross-references a number of l
19 contentions in that.
20 A Yes.
21 Q Would your answer be the same with respect to the 22 contentions cross-referenced in 50-B?
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1 A Yes. Let me just check that. 33, 35, 39, 41, 42, 2 45, 49. Yes.
3 Q Dr. Perrow, it's 35 through 39. Did you 4 understand it that way?
5 A Yes. That includes a couple of my favorites.
6 Q With respect to Contention 50-C, would your answer 7 be the same for the contentions cross-referenced in 8 Contention 50-C, which include Contentions 34 through 39, 41, 9 42 and 45?
10 A Yes.
11 Q Certainly if you feel you need to look at any of U 12 those, they are available and you may do so if you like.
13 A I remember them.
14 Q Would your answer be the same with respect to the 15 contentions cross-referenced in contention 50-D, which 16 include Contentions 41, 42 and 45.
17 A Yes.
18 Q Would your answer be the same with respect to 19 Contention 50-E, which cross-references contentions 34 20 through 43 and Contention 45?
21 A Yes.
22 Q Would it be the same with respect to Contention '
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%J 1 50-F, which cross-references Contentions 37, 38, 40-C and 2 43-A?
3 A Yes.
4 Q I think that we have already been through G and 5 H.
6 A Yes.
7 Q Dr. Perrow, did you come to Washington 8 specifically for the purpose of giving this deposition today?
9 A Yes.
10 MS. MONAGHAN: I have no further questions. Thank 11 you.
12 MS. MC CLESKEY: No questions.
13 MS. LETSCHE: I have no questions.
14 MS. MONAGHAN: I would like to adjourn this 15 deposition subject to recall. In the event that Dr. Perrow 16 has the opportunity to review some additional documents, we 17 g may wish to recall him at a time when he is better able to 18 answer specifically the facts and opinions to which he is i
19 l going to testify.
20 MS. LETSCHE: Let me just state for the record f 21 l that this deposition was taken upon notice by LILCO at the 22 present time requested by LILCO and Dr. Perrow has testified l
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I that to the best of his abilities, given his current 2 opinions, and if LILCO wishes to attempt to renotice the 3 deposition, I don't think there will be time to do that, 4 given the deposition schedule, but at this point the 5 deposition, as far as we are concerned, has been concluded 6 and we are not going to agree to reproduce him.
7 MS. MONAGHAN: Certainly we can deal with that 8 with the licensing board, but the deposition is adjourned.
9 Off the record.
10 (Whereupon, at 2:40 p.m., the deposition was 11 adjourned.)
-3 12 ,
13 42 , gqh 14 CHARLES PERROW 15 16 Subscribed and sworn to before me
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18 -
Notary Pubuc 19 My Ccmmission Expiros )
20 21 22
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CERTIFICATE OF NOTARY PUBLIC & REPORTER 168 '
(]
officer before whom
'I, WENDY S. COX , the the foregoing deposition was taken, do hereby certify .
that, the witness whose testimony appears in the ]
1 foregoing deposition was duly sworn by me; that I
the testimony of said witness was taken in shorthand and thereafter reduced to typewriting by me or under my direction; that said deposition is a true record )
of the testimony given by said witness; that I am neither counsel for, related to, nor employed by any of the parties to the action in which this (
deposition was taken; and, further, that I am not
[
a relative or employee of any attorney or counsel O .
emotored hv ehe gereies hereto, nor finencia117 -
or otherwise interested in the outcome of this action..
Notary Public in ind for the District of Columbia My Commission Expires 11/14/87
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6/86 Curriculum Vitae Charles B. Perrow Education University of California, Berkeley B.A. 1953, M.A. 1955, Ph.D. 1960, all in Sociology Present Position Professor, Department of Sociology Yale University, Box 1965 Yale Station New Haven, Connecticut 06520 Personal Born 1925, Tacoma, Washington Married, two children -
Social Security No. 532-18-41.0.7.
Teaching Positions 1astructor to ^==1=t at eroce==or. oepart= eat or O '959-1963 Sociology, University of Michigan, Ann Arbor.
Assistant to Associate Professor, Department of 1963-1966 Sociology, and the School of Public and International Affairs, and the Administrative Science Center, University of Pittsburgh.
196'6-1970 Associate Professor to Professor, Department of Sociology, University of Wisconsin; Head, Social Organization Center, 1966-1970.
1968-1969 Visiting Professor, Institute of Industrial Relations and School of Business Administration, University of California, Berkeley.
1970-1981 Professor, Department of Sociology, State University of New York at Stony Brook.
1972-1973 Visiting Professor, London Graduate School of Business, London. '
1981-1982 Fellow, Center for Advanced Study in the Behavioral Sciences, Palo Alto, California.
O 1981-eres. erofeesor.
University.
De.part eat of Socio1osv. 1 1e 4
- - - ~-
2
.o
] Maior Research Grants NIMH Predoctoral Fellowship. Goals and authority 1957-1958 in general hospital.
1958-1962 NIMH Grant. Associate Study Director, comparative study of seven juvenile correctional institutions.
1963 NIMH Grant. Panel study of a correctional institution.
1965-1967 NSF Grant. Comparative study of eight industrial corporations.
1967-1968 NSF Grant and Vocational Rehabilitation Grant, Comparative study of fourteen industrial corporations.
1971-1972 NIMH Grant. Insurgency and social change in U.S. , ,
1948-1970.
1973-1976 NIMH Grant. Insurgency and. social change in U.S.,
1948-1972.
1978 NSF Grant. Origins of industrial- bureaucracy in O the U.S.
V 1980-1982 NSF Grant. Accidents in High Risk Systems.
1982 Of fice of Naval Research Grant. Organizational Context of Human Factors.
Consultancies and Minor Grants 1956-1958 Evaluation study for OVR of Home Care Program, Mount Zion Hospital; Evaluation study of alcoholic rehabilitation program, California State Alcoholism Commission.
1963-1964 Evaluation study of half-way home program for Federal Bureau of Prisons (with other co-investigators); Consultant and research role for City Youth Commission.
1974-1975 Consultant to Philips Industries, Eindhoven, Holland, on work structuring program.
1972-1973 Consultant on various projects in public sector for Imperial College of Science and Technology, London.
3
] consultancies and Minor Grants (continued) 1972-1975 Workshop leader, for Dale-Loveluck Associates, running two-day workshops for executives in London.
1973-1974 Evaluation study of administrative practices in student services at Stony Brook.
1975 Consultant on evaluation strategies for AID rural health programs; Consultant, Office of Tele-communications Policy, electronic funds transfer.
1979 Background paper for President's Commission on the Three Mile Island Accident, "TMI--A Normal Accident."
1979 Consultant to Institute of Public Service, New '
York City, interview and surveys of New York City .
Welfare. Department employees.
1979-1980 Nuclear Regulatory Commini.on, panel member of Safety Goals for Nuclear Power Plants conferences.
1980-1981 Battelle Institute, panel member of group studying O the optimum organizational structure for nuclear power plants, sponsored by the Nuclear Regulatory 1 Commission.
1981-1982 Dioxin in the Office Building: the Generation of Risk Assessment in Terms of Personal Tragedy and Organizational Dilemmas. Russell Sage Foundation, small grant.
1982 consultant to Institute of Public Service, New York City, on survey of employee attitudes for Citibank.
1982 Testimony for Friends of the Earth at the Indian Point Restart Hearings before a three person special Federal Judge panel.
1985- Consultant to law firms regarding chemical plant accidents.
1985- Pro bono work for the Oil, Chemical and Atomic Workers Union, regarding chemeial plant safety.
Teaching Interests O Complex Organiza tions, Industrial Society, Technology and i Social Change, Social Movements, Research Design, l Sociological Theory.
_ .- 4,a .m . .._m _ _ . _ m_ m ... m m _m_
1 4 l
. ;. \
~
Honors and Memberships i
Phi Beta Kappa; Newhouse Fellowship (University of California)
Public Health Pre-Doctoral Fellowship Public Health Service, Special Fellowship Vice-President: Eastern Sociological Society National Association for Advancement of Science, Fellow 4 . National Research Council, Committee on Human Factor Research, 1981-83 Editorial Board Membership: American Sociological Review, Administrative Science Quarterly, American Journal of Health and Social Behavior, Administration and Society Council Member, Section on Professions and Organizations:
American Sociological Association Sociology Panel: National Science Foundation '
Senior Research Fellow: Center for Policy Research Member
, AAAS, Nominating Committee, Section K.
4 Industrial Relations Association Eastern Sociological Society.__ -
International Sociological Association Normal Accidents recipient of the 1985 George R. Terry
- Book Award, Academy of Management.
I Books and Published Monograchs i 1. Studx an Lhn Enn=Sastnsaktd Haasikakization ni i Alcoholia fatiinia in a Qinital Haanital, (American Hospital Association, Hospital Monograph Series 7,
- l. 1959) with Mark Berke, Jack D. Gordon, M.D., and Robert j I. Levy, M.D., 120 pages.
l 2.
Organization far .Ireatment: A famparative Study of l Juvenile Correctional Institutions, New York: The Free l Press, 1966) with David Street and Robert D. Vinter.
l l 3 Organiza11snal Ana12 alai A Snsininginal Yinu, I
Belmont, Ca.: Wadsworth Publishing Co. 1970, (Chapters have been reprinted).
l
- 4. 12m2111 Qrganizations: A fritical Essa 2, Glenview,
[
Ill.: Scott, Foresman, 1972. (Chapters have b e,e n reprinted.) Revised edition, 1979 Third edition:
1986.
, 5. Ihn Radisal A11ask an Ruainmaa. Harcourt Brace l
Jovanovich, 1972.
6., Normal Accidents: Living with High Risk Technolonies, Basic Books, 1984.
i
-m.---,m . _ _ _ _ . _ , . - . _ _ - , , , - - . . . _ , ~ _ , _ - , _ _ _ _ _._--,-_._ _ ......,. _ __. -_ _.. . -
1
~
5 l
i j
Egs,earch Articles gr Chanters
- 1. "Are Retirement Adjustment Programs Necessary?," ,
Harvard Business Review, 35:4 (July-August, 1957), 109-15.
A Critical Ana1ysis of
- 2. "Gemeinschaft and Gesellschaft:
the Use of a Polar Typo 1ogy," Berkelev Publications in Institutinns and Society, 2:1 (Spring, 1956), 20-43 A1so reprinted in Autonomous Grouc Bulletin, XIII:1, 2 (Autumn-Winter, 1957), 10-16.
3 "Research in a Home Care Program," American Journal nf Public Health, 49: 1 (January, 1959), 34-44.
- 4. " Nonsegregated Hospitalization of A1coholic Patients in a General Hospital," HnA2itala, Journal of the American Hospital Association, Vo1. 33, (Nov. 16, 1959), 45-48, with Mark Berke, Jack D. Gordon, M.D.,'
and Robert I. Levy, M.D.
" organizational P r+ s t-i g e-t-- -S o m e Functions and
- 5. 66: 4 Dysfunctions," American Journal af Sociolog.Y, (January, 1961), 335-41. Reprinted in 3 books.
d 6. "Rea11ty Shock: A New Organization Confronts the Custody-Treatment Dilemma," Social Problema, 10:4 (Spring, 1963), 374-82.
- 7. "Goa1s and Authority Structures, A Historical Case Study," Chapter 4 in Ihm Hnan11al in Bodern Society, Eliot Freidson, (ed.), (The Free Press, 1963), 112-46.
- 8. " Sociological Perspective and Political Pluralism,"
snnial Haamarch, 31:4 (Winter, 1964-65), 411-22.
Reprinted.
- 9. "The Re1uctant Organization and the Aggressive Environ-me n t ," (with John Maniha), Administrative Science Quarterly, 10:2 (September, 1965), 238-57. Reprinted.
- 10. " Hospitals: Technology, Goals and Structure," Chapter 22 in Handbook of Organizations, James March (ed.),
Rand McNally, 1965), 910-71.
- 11. " Reality Adjustment: A Young Institution Settles for Humane Care," Social Problems, 14:1 (Summer, 1966), 69-79.
O 12. "Techno1ogv end Organizationa1 Structure,- ereeee41nas of the 19th Annual Meeting of the Industrial Relations Research Association, December 1966, 156-63
,,.,_______r_m., . - - _.-.i.- - - . , - - , , - . - - . - - - - . -
7 ._,y- .
6
(] Research Articles nr Chanter (continued)
V 13 "A Framework for the Comparative Analysis of Organizations," American' Sociologi. cal Reving, (April, 1967), 194-208. Reprinted several times and in Bobbs-Herrill Series.
- 14. " Organizational Goals," International Enevelooedia of ihm Snnial Sc i e nnas , r e v i s e d e d i t i o n , ( M a c M i ll a n C o . ,
1968), Vol.11, 3 05-11.
- 15. "The Professional Army in the War on Poverty," " Focus Article" in Enyar1X and Human Easources Abstracts,
( J a n ua ry-Februa ry, 1968).
- 16. " Technology and Structural Changes in Business Firms,"
Indsatrial Halatians_:. fanimmantarX Issuga, B.C.
Roberts, (ed.), (MacMillan Co., 1968), 205-19
- 17. "Some Reflections on Technology and Organizations," in
- A. R. Negandhi, et al. (eds.), Inmaara1121 Administra11nn and Managamani, comparative Administration Research Series, No. 1 (Kent State University Press, Kent, ~0hio, 1969).
- g. 18. " Members as a Resource in Voluntary Organization," in Organ 12 A11nn and flignis , W . R o s e n g r e n a n d M . L e f t o n ,
(eds.), Charles E. Merrill, 1970,93-116.
19 " Departmental Power and Perspective in Industrial Firms," in Engar in Organizations, edited by Mayer Zald (Vanderbilt University Press, 1970), 59-89
- 20. "The Short and Glorious History of Organizational Theory," Organizational Dynamis1, (Summer 1973), 2-16.
l (Reprinted) l l 21. " Zoo Story, or Life in the Organizational Sandpit,"
l Chapter in course text, Peoole and Organizations, Open l
University (England), 1974. Revision for 1980 edition.
- 22. "Is Business Really Changing?" Organizational Dynamics (Summer, 1974). (Reprinted) i l 23 "The Bureaucratic Paradox: The Efficient Organization i
Centralizes in Order to Decentralize." Organizational Dynamina, Spring, 1977, 2-14. (Reprinted)
- 24. "Three Types of Organizational Effectiveness," in Paul S. Goodman and Johannes M. Pennings, ed. Hex A Efrap1111XAA O n OrKan12111nnal E f f e c t i v e n e s s , Jossey-U Bass, 1977,96-105.
t l
7 6 ,
Research' Articles an Chanters (continued)
(,,)
- 25. " Insurgency of the Powerless: Farm Worker Movements, 1946-1972" (with Craig Jenkins), American Sociological Review, 42, (April, 1977), 249-68.
- 26. "Demystifying Organizations" in Rosemary C. Sarri and Yeheskel Hasenfeld eds. Ihm Managamant af Human Services, (New York: Columbia University Press, 1978).
105-122.
- 27. "The Sixties Observed," in Mayer M. Zald and John D.
McCarthy, eds., Ihg Dynamism af Social EnXAmania, Cambridge, Mass., Winthrop Publishers, 1979, 192-211.
- 28. "The President's Commission and the Normal Accident,"
in David Sills, et al. (eds.) Ihg Accident al Three M11g Island: Ih1 HMman Dimensions, Boulder, Colorado:
The Westview Press, 1981.
29 " Disintegrating Social Sciences," Ham York University Education Quarteriv, vol. 12, no. 2 (Winter, 1981), 2-9.
- 30. " Markets, Hierarchies Ynd ~Fegemony: A Critique of Chandler and Williamson," in Andrew Van de Ven and g William Joyce, eds. Eerspastives an Ongani z a t ion Q Design and Behavior, New York:
1981, 371-386, 403-404.
Wiley Interscience,
- 31. "This Week's Citation Classic," C u r r e nt .Cante n t s , 14 (April 6, 1981), p. 14 (A reflection on item 15-
" Framework. ..) "
- 32. " Normal Accident at Three Mile Island," Society, vol.
18, no. 5 (July / August, 1981), 17-26.
33 "Three Mile Island: a Normal Accident," David Dunkerley and Graeme Salaman, eds., Ihr International Inarkonk nf Drganiza11sn Studit n, 1981, London:
Routledge & Kegan Paul, 1982, 1-25.
- 34. "The Organizational Context of Human Factors,"
Technical Report, U.S. Navy, Of fice of Naval Research, Washington, D.C., November, 1962, 1-50. DTIC
- ADA123435.
- 35. "The Organizational Context of Human Factors Engineering," Administrative Science Ouarteriv, vol.
28, Cornell University, 1983, 521-541.
- 36. "Journaling Careers," i n L.L. Cummings and Peter J.
s Frost, eds. Publishing in thg Organizational Sciences, Homewood, Ill.: Richard D. Irwin, Inc., 1985, 220-230.
i 8
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Research Articles ,qr Chanters (continued)
O 37. " Comment on Langton's ' Ecological Theory of Bureaucracy,'" Administrative Science Quarter 1v, vol.
30, 1985, 278-283.
- 38. "Journaling Careers," Sociological Forum, 1:1, Winter 1986, 169-177.
39 " Risky Systems: The Habit of Courting Disaster,".The Nation, October 11, 1986.
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1 16 -
I i f
- The President's Commission and 1 I
the Normal Accident - I e
Charles Perrow i -
This chapter incorporates the major points of an analysis of the accident at
- Three Mile Island that I prepared in September 1979. In contrast to the find. !
ings of the President's Commission (1979), I did not view the accident as the .
i result of operator error, an inept utility, or a negligent Nuclear Regulatory Commission but as a consequence of the complexity and interdependence that characterize the system itself. I argued that the accident was inevitable-gj ,
l ..
that is, that it could not have been prevented, foreseen, or quickly termi- 'I !
nated, because it was incomprehensible. It resembled other accidents in nuclear plants and in other high risk, complex and highly interdependent operator machine systems; none of the accidents were caused by manage. -l ment or operator ineptness or by poor government regulation, though these 1' characteristics existed and should have been expected. I maintained that the accident was " normal" because in complex systems there are bound to be multiple faults that cannot be avoided by planning and that operators cannot .:
immediately comprehend.
{,
Although the improvements recommended by the commission are sorely 3 t.
needed, they will not prevent normal accidents. At best. they will slightly reduce the frequency of other kinds of accidents and the frequency of nor-f 1
' mal accidents by only a few percentage points. My analysis implied that there can be no tolerable level of risk for complex, tightly coupled operator. .
! machine systems having disastrous potentials. In this essay I resiew the argu-i ment and discuss its implications for the commission's poution. - l- -
f l Systemsand Accidents All systems' are prone to accidents. However, most xcidents have negli- t gible consequences, even those in complex operator-ma; hine systems whose risks are high.High risk systems-such as nuclear power generation, the manu-l i
1 73 \
i N
- _ _-- mmi
i.__..
I74 '
Charles l'erro a facture of toxic substances, mass transit (airlines and rauenger trains),ge.
netic experiments in research laboratories, military adventures, and to some
- degree the transport of d.ngerous substances- v nerally have redundant or
- backup equipment, systems, personnel, and pbns degned tc ha'1dle faulty eqgipment, operator error, or environmental distm'nnces. They also centain C warning and emergency systems to bring the '.mton ard deselopments to ::
halt. No equipment, operator, design, er environment is Perfect. and so one '
designs systems taking faults into account. '
Those few significant accidents that do occur in complex, high risk sys.
- tems are usually the result of either: (1) known and caleufated risks:(2) dis.
crete equipment or operator failures (one or two malfunctions and the safety I system does not respond properly);or (3) a unique event, such as a natural ! i disaster, that is unforeseeable. Natural disasters cannot be prevented but are l *
' quite rare. Discrete failures can be prevented from recurring by using *:stter '
, t equipment, design, or training. Calculated risks can be recalculated and the
, i
- system altered. In these ways we prepare ourselves to live with risky systems; e, sunilarly, the commission proposed we prepare ourselves for nuclear energy in these ways. 1
- v One other type of accident-more menacing than any of these-is the
" normal accident."It is termed normal because it is inherent in the character.
^
lg istics of tightly coupled, complex systems and cannot be avoided. A tightly , 0 I k,, coupled system is highly interdependent;each part is linked to many other
- u 5 parts, so that a failure of one can rapidly affect the status of others. A mal- ,
-=
functioning part cannot be easily isolated either, bec suse there isinsufficient I$ h lf time to close it off or because its failure affects too many other parts, even if the* failure does not happen rapidly.
g si A normal accident occurs 11 a complex and tightly coupled system when
- at there are unanticipated multiple failures in the equipment, design, or opera-
>$ tot actions. Although there may be a discrete source, it will interact with st
'y other unknown or unanticipated conditions that alone would be insignifiedht vi jy and could be corrected, but that, in combination wi'h the initial failure, pro- ,
f
. i ip duce unexpected interactions. In contrast, a discrete accident may produce te -
' several interconnected events (including some failures): however, the failures '
t:
are anticipated or comprehensible, and the operators evi take remedial N'
actions. The crucial point about a normal accident is that unexpected, mul-
_ tt tiple failures occur, As a result, for some critical period of time the nature of
,4 ti.
the accident is incomprehensible to those who are seeking to control it,
, rs in addition to being unfereseeable, incomprehennble. and not amenable
{
E M
to knowledgeable intervention, the normal accident cannot be prevented be-cause it is not possible to create faultless systems. Of course, some systems U
can be r~nore accident prone than others and thus more subject to normal and K-other kinds of accidents. If they are sufficiently complex and interdependent, vi<
i t
1
+
_ _ - , _ _ _ _ _ _ _ _ _ _ - _ - - - - - - - - - - - - - - - - - - - - - ^ -
l Charles Perrow The President's Commission and the Normal A ccident
- i 73 . f _,
- ie
'f i
enger trains), ge- the normal accident will occur even in weil run, welldesigned systems. In
, .res, and to some addition, there is a point at which safety systems increase the complexity of '
l redundant or the system so rapidly that they can generate rnore normal accidents than they Q handle faulty , prevent. (In effect, Babcock and Wilcox experts testified to this possibility
,fg they also contain wii rn aged why various safety systems were not included in the r: actor they I
velopments to a buit for Thr.e Mile Island.) Even rare accidents cannet be tolerated in
> feet, and so one [
systems whose potential for harming public health is disastrans.
-[
' -ll Three Mile Island: A Normal Accident
) dis.
ns and the safety I conceived the idea of a normal accident after reading the transcripts of i such as a natural the first commission hearings. I realized that all of the interacting, exotic prevented but are 'l failures were not exotic at all but were typical of many institutions and or- .!
- by using better ganizations. Murphy's I.aw-if anything can go wrong it wd!-is actually not ,
dculated and the correct. To be sure, discrete errors and failures are legion; there are always ith risky systems; at nuclear energy many more errors than accidents, precisely because most systems are not 2 highly interdependent and all have redundant features. In most systems, even when errors do occur, there are usually other undisturbed pathways that d
of these-is the permit the errors to be corrected. At Three Mile Island, this was not the case, h,
- . in the character- The accident at TMI displayed the four characteristics of normal acci-i ,oided. A tightly dents: warning signals, equipment and design failures, operator errors, and '
d to many other unanticipated events. !i of others. A mal- l ere is insufficient ##'"l"8 D #
other parts, even Warning signals appeared before the accident in the form of records of similar accfdents, reports predicting such an accident, evidence of persistent !
led system when and uncorrected equipment failures, and evidence of operator failure. All the Jesign, or opera-f signals were disregarded or dismissed. In normal accidents, signals are simply O pteract with viewed as background " noise" until their meaning is disclosed by an accident. !
l e insignificant iitial failure, pro-Furthermore, although the plant at TMI was tightly coupled, the industry w itself was loosely coupled; thus, warnings originating in one part of the sys- ]g
.nt may produce tem (from another plant, an engineer at the Tennessee Valley Authority, a ever, the failures [ ,
technical report from Battelle Memorial Institute [ Columbus, Ohio], the ;' ,
o take remedial NRC, etc.) are screened, buffered. delayed,and interpreted b: fore they reach I mexpected, mul- the part of the system that might use them.Thislooseness was intentional; a me the nature of tightly coupled nuclear industry might not be profitable and would require a [
s l .g to control it, rigidly authoritarian structure that could not be managed. :
- d not amenable
(
ac prevented be. Equipment and Design Failures y
e, some systems Failures inethe design of the plant and in the equipment were manifold.
- t to normal and Key valves failed and had failed before; equipment was out of service,which
[
interdependent, violated federal rules; leaks abounded; and indicators malfunctioned. The b '
.'6 '
5 ' ,
t
' .g s Q
l
I i 176 Charles Terrow y i
l e commissioners were appalled at the condition of the equipment. But intersive
- investigations of .ierious accidents almnst always disclose widespread equip-
! ment failures and violations of rules and procedures; the<e are usual for sys-tems but remain unremarked upon or unno'n.ed until 5,s stems are investigated ca.
l her ft accident. llistorians tell us the causes that should explain wars gen. ,~
po-l etally exist when no wars occur;in our rassion to understand and create an the i orderly universe we explain the unusual event by invoking the usual and pro- . cla I claiming it to be different, when of course it is not. Instead.it is the obscure, eq:
I , accidental, and even random concatenation of normal disorders that produces sta l a great event that we assume must have had grest causes. th-ac Operator Errors
,9(
! The major operator " error" was throttling back on two high-pressure in. du i jection pumps to decrease water pressure, thus aUowing the core to become coi l
{ uncovered and to overheat. However, this is a clear case of retrospective error, '
- to!
l a judgnienTihit could have only be' en made'after the fact. Although theiom-
~
i
' mission had evidence that it was a rettdspictive' error, they avoided drawing #
l that conclusion. Unless one knows.that the accident invohes loss of coolant
'I" l4 '.
l to the core (a loss of coolant acMent or LO_CA), the recommended proce-
- dure is to throttle back in. order to_ avoid othe,r kinds of damage. There was no be jo direct way at TMI to determine that they were experiencing this particular J an-p form of LOCA; utdeed, the readings of the core that are normally used to Br j p determine the amount of coolant present indicated there was enough coolant. -,. the i
g The decisions of the operators were plausible, though erroneous. It was some . - m.
hours later, and much too late to matter, before even the outside experts were able'to realize what had actually happened. Ilaving errors retrospectively l on f ,
{ (ir p attributed to them is a typical fate for operators in normal accidents. ( ce
{tt
(
I*
, Unanticipated Events ,
sy J. The combination of design failures, equipment failures, and operator error g th produced interactions whose consequences exceeded or were different from
8 l $1l . those of any individual failure.The effect is synergistic, that is, the sum of the Tll ha ,
I ,. whole is more than the sum of the parts analyzed individually. The operators an '
l i. testified that they were bewildered by the event. Even Babcock and Wilcox ! dc experts, who blamed the accident on the operators. testified that at the '. es l1 crucial period the contradictory readings were mysterious to the operators, tu ,,
-[ given what they knew the equipment should be doing and their standard sa j emergency operating procedures, m;
- I Thus, my report concluded that the accident was unexpected, mcompre- !
. hensible, uncontrollable, and unavoidable; that such accidents had occurred il '
l before in nuclear plants,2nd would occur again, regardless of how well they m were run. sa l l
.. - I l!
1.
!l:
.__ .-- A-
i e Charles Perrow The President's Commission and the Normat .1ccuent i77 .
i$
u nt m The Commission's Analysis usual for sys- The commission's conclusions were quite different. In brief, the report i
de investigat4 contended that if fundamental changes are made in the industry then nuclear !lf explain wars gen-f p er pn become a tolerable risk. To reach this conclushu. they argued that nd and create an
((
j th mapr cause of the accident was opentor error; v e sha!! examine this
-he usual and pro- claim fa detail. They also assumed that Stetropolihn Edimn's Olet Ed) 7;.
] . it is the obscure.
equipment, methods, operator traininc. and generai attitude wcre well below l.
j crs that produces standard and that an accident at the I\ll plant was inevitable because of l' these conditions. Finally, they assumed th1' the less pmximate causes of the l q; I accident-the ineffectiveness of the NRC and the attitudes and practices of .
l the industry in general-can be remosed through major reforms of the in.
I i high pressure in. dustry. Further,if such reforms are made, no plants wul be operating under I b'!
i : core to become conditions such as those that existed at TMI, and nuclear power will be .
I l i trospect_i_ve error,
- k tolerably safe. Y
.ithough the com. H avoided drawing
- N'" POII'"" U5'*"""0 es loss of coolant 1 the Three Mile Island Plant yj
'e, ammendedd pr_oce- Were the conditions at Met Ed that unusual? Aside from Dil, there have ;
l age. There was no been about eight serious accidents in the short life of nuclear power plants, l j .nglhis particular and there is no evidence that these eight plants (including Shippingport, j l normally used to. Brown's Ferry, Davis Besse, Fermi, and Pdgrim 1) were more poorly run than !
j s enough coolant.% the others at that time. Many accidents have involved no particular mis-
.eous. It was some management at all but were merely bizarre interactions of small failures. In c outside experts one case, for example, a short circuit in a reactor required a scram procedure its retrospectively (in which control rods are dropped into the reactor to stop the fission pro-ecidents. * ;
, cess). However, the short circuit fused the wires in another circuit that af. {
fected the scram system, thereby producing a false reading that the scram ,
1 O
nicperator error
- system had been activated. In fact,it had done just the reverse-sent power to the motors that prevented the rods from dropping.The reactor did not scram y l re different from The bewildered operator could not have been expected to know what had l ts,the sum of the happened. Fortunately, it was a government reactor producing plutonium, ,
! ay.The operators
- and it had a backup scram system that worked m time to prevent a melt !
i cock and Wilcox I down. But the bizarre nature of the short circuit fusion might have defeated {
j 6 tied that at the even the backup system if the design had been somewhat different. The ,
I to the operators, . history of nuclear accidents is filled with such events. none of which n,eces- ,
d their standard sardy implicated the quality of management or the NRC, though the latter i might consider retrofitting all plants with backup scram systems. ;
acted, incompre- The criticisms of Met Ed by the commission were blistenng (and justi- }
nts had occurred fiably so), but the scanty attention that the NRC extended en plant ratings of how well they indicated that TMI was an average plant. Its engineermg capabdities, the NRC ,
' said, were about average, and its operators tested above the national average h,
7 l
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I
__ ____ _ . . _ . - . _ - _ -- - - - - - - - - - - - - - ~~-- --~
q .
M 1
Charks lyrro s: ,' Th.
i in the routine NRC examinations. The commission seerned wedded to the as. ,
by sumption that this plant must have been particularly derelict. Because the can j j operators tested above average, they concluded that t'ie tests were inade. wit' q '
~ '
n te,Inot I .
that the operators experienced a problem even the experts could ,
tha-
I yea j OperatorError I wer g
' J g,o l _; Operator error is frequently cited u the most important cause of the acci. -
l-
{ , dent. This thesis is worth examining in detail, for it hides more than it ex. une j ,
plains Because of the complexity of the "trsnsient"(this technical term indi.
' in
cates a loss of coolant, rather than anything temporary or ephemeral),it will
- to r i ;
be necessary to simplify the account. The transient originated in a problem the.
l l with filtering resin from water ilowing to the steam generators that create
' j A di stearn that drives the turbines. The problem had occurred twice at the plant, cate-j - ,
and the system was being repaired. This time, the blockage caused a pump to , wee j i stop (or trip), thereby automatically trippin. Ae turbines and activating some on a j ,
other emergency pumps, but the pipes from t..e emergency pumps had erro. dise-neously been left blocked during mamtenance work two day s before. (This is leak j one case of gross operator error, but hke everything else that went wrong, not caus j too significant in itself.) The core then started to overheat,because water was ,
ic
) I pi not flowing through the steam generator to remove heat from the separate i t'
} coolant system in the core. The reactor scrammed, as designed, stopping the '.; t r-1 I. fission process (though there was still" decay heat" generated in the core). As '
1
.I9 the reactor heated more and pressure increased, a pressure operated rehef ,' t' ri/
i lM, valve (PORV, sometimes referred to by its Dressler industries trade name, lff ca.
8 "electromatic relief valve") opened as planned to alleviate the increasing pres. 'y d sure. The reactor pressure retumed to normal (we are now 13 seconds into .. and '
! the transient), but the PORV did not reseal,even though the indicatcr on the cold
{ ,
s% control panel indicated that it had. The operators assumed the valve had ? were !
I 'l closed. Because the valve remained open.a loss of coolant accident occurred, S dise" l lhl as coolant for the core was passing through the open vabe and draining into a tank. The operators only knew that there had been a brief accident that had that of th l
tripped the turbine and scrammed the reactor.They did not know they were ' T!
l in a LOCA for almost two and one. half hours. By then the damige had been ; tors. '
i !
f i done. l train Meanwhile, the pressure of the coolant had dropped, and it was in dang'er Coc-1 j of turning into steam unless it stayed under pressure. The high pressure in. , co" jection (IIPI) pumps came on as designed, forcing water from an emergency opet t
tank into the core coolant.The operators saw that the level of pressure in the p. I ;
pressurizer rose rapidly. Not knowmg they had a LOCA. they cut back on the fron-
, pumps to prevent the pressurizer vessel from becoming a sobd mass of water, oper I which could
- rupture the reactor coolant system. Retrospectively, this is seen - -
the)
I 4 i
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e Charles Perrow The President's Commission anJ the Ncrmal .4 ccidee U9 .
I 3
.vedded to the as- ,
by all commentators as the major error. Operators did not r:'ahze the signifi. ' ,' [
lict. Because the cance of a corresponding drop in pressure in the core i:self. it was not tilled j' i
O were inade, with liquid coolant, as they assumed, but with a mixture of steam and water 'i bexperts could '
that contained many voids or bubbles. Operators at a Davis Besse plant a .li y4 e$r also experienced a Jammed PORY and aim < lid not know they w& in LOCA, so they also cut back en the HPl. Fortunately,there was no .ll damage. -
cause of the acci- i How could the TMI operator not have discovered th1t the core was being -l more than it ex. uncovered and superheated? There is no direct reading of the level of coolant h
,hnical term indi- ; in_the core;a Babcock and.Wilcox official testified that it would be difficult ,
phemeral),it will '
to provide, too expensive, and would create other compheations. Although p p ted in a problem thtre were several indirect measures, each proved to be faulty or ambiguous. ,
rators that, create ,
Adrain-tank pressure indica. tor would have suggested a LOCA,butit was to.
~ l avice at the plant, cated on the back side of the seven foot control panel; unaware that they ;,f caused a pump to _were in a LOCA, the operators had no reason to look at it. The temperatures 3
.J activating some { on a drain pipe would have indica:ed the problem, but the operators had been i
' pumps had erro. discounting these readings prior to the accident because the drain pipe had
( ! )
> s before. (This is .] leaky valves, and they assumed that a particularly high reading had been l
- . went wrong, not g caused by decay heat.What about the drop in pressure in the core itself7 This i
ecause water was indicator of core pressure was next to the indicator showing a rise in pressure !
' rom the separate in the pressurizer. These two indicators were supposed to move together; }
aed, stopping the therefore,it was inconceivable to the operators that one would drop as the d in the core). As other rose. They believed the indicator that measured pressure in the pres-j J operated relief surizer and throttled back on the !!Pl; they discounted the indicator that ries trade name, } measured core pressure, as they thought that the indicator said the POVR
- e increasing pres. had closbd,because pressure had brietly risen in the core and then fallen off l
13 secoads into , and because the pressure decline could have been due to a sudden injection of
' cold water. Finally, they were accustomed to receiving faulty readings-there i e 'nHeator on the
~
j ) valve had were several during the transient-so they relied on those that made sense and ;
- endent occurred, discounted or explained away those that did not. Finally,it should be note (
{
d draining into a 4 '! that the control room quickly filled with managers and engineers, and none i .ccident that had l of them knew that the problem was a LOCA.
j know they were '
This evidence came from the commission heanngs. Regarding the opera.
j hmage had been I, tors, the commission concluded that there was "a severe deficiency in their i training" because they failed to realize they were in a LOCA (President's ,
. it was in danger { Commission 1979, p. I16); that they were " oblivious" to the danger of t:n. ; i high pressure in- ! covering the core; and that two readings "should have clearly alerted the
'i an emergency operators that TMI.2 had suffered a LOCA"(President's Commission 1979,
- af pressure in the ,
p.113), llowever, commissioner Theodore Taylor, a theoretical physicist I cut back on the from Princeton University, argued specifically that there was no way for the ,
d mass of water, ' '
operators to know what kind of an accident they were experiencmg when ively, this is seen they cut back on the llPl. Taylor noted that the decision to cut back on the L .
I N. .,
l I l l M Choles ferrow Thein l s
! HPI must be made before one can know that it would be the wrong decision.
} dorsing f
Despite these considerations, the commission report suppo:ted the retrospec- instead ll tively reached industry judgment of egregiom operator errer. So widely ac- the sv.
i cep is this view that the British Secretary of State fcr Lnergy referred to them fit j th usq8if the accident.as " stupid errors" (Science.19 October 1979,
! p.3 ).., institut;
) :
6 Consider the situation: 110 alarms were sounding: key indicators were in. The-j accessible; repaitorder tags covered the warning lights of nearby controls; the
- a wide e i
) data printout on the computer was running behind (eventually by an hour industrs j ?
and a half); key indicators malfunctioned; the room was filling with experts; issue E j f and several pieces of equipment were out of service or suddenly inoperative. NRC an-j [ In view of these facts, a conclusion of " severe deficiency in tratning" seems very gee j ; overselective and averts our gaze from the inevitability of an accident even if NRC are j r training were appropriate.
strength-Normal accidents have banal causes. Almost all of th many things that upgrade l went wrong during the transient had gone wrong before; none was cata- enforce
( strophic in itself. However, banal causes become bizarre events in complex, I deadline-l ; tightly coupled systems. During an accident these causes are incomprehen- opportu:
{ sible (or will be to some set of operators at some time, regardless of training). conduct .
- i For this reason there have been many nuclear accidents and there will be , impr 9 j more. ,' revie p L,py Though parts of the report focused on operator error as the major cause of D ii j
Ip the accident, ether parts (and considerable testimony at the hearmgs) demon. *
'a e-l 4 strated how difficult it is to separate operator error from design and equip- i gv j I
ment failures and commercial pressures. Plant policies, plant designs, and t g j
j lh
,y 7 equipment all contribute to operator error. The woefully inadequate control panelis a case in point. Numerous technical studies, conferences,and reports i I- Indu't r<
l on the subject have produced no apparent effect in the industry. The most ,
guide. R-l %, complete study of the problem, conducted by Lockheed Missiles and Space have neir
. i Company for the EPRI in the mid 1970s, concluded that operators work 4 . ;. ' .ernmen t I
lh under severe handicaps. It is the operators who have exhibited ingenuity in using colored tape, homemade control knobs, and homemade supplemental i 8.. cantsafe*
cal labor
, equipment to highlight the logic of the sy stem, which is so haphazardly dis. , tional 52 played by equipment manufacturers and ignored by the NRC. Operators ; labels th' err,it seems,in not being able fully to surmount the inadequacies and com. ( cessfully plexities of the equipment they must use.
- Adminis'
. The report correctly recognized that the problem was an operator machine l series of one. Still, it stopped short of acknowledging that for systems of this com. children?
, plexity and because of the inevitable limitations of equipment. designs, and and an in 1 operators,even better training, qualifications, and quality control are unlikely unanimo" to make more than a modest improvement. Thus, the report ref rains from en. bers of t!
l t
y
, 1 i n
.l. #
Charles Perrow The Pressdent's Commission and the Normal Accident 181 d
l a the wrong decision. dorsing this conclusion sbout high risk and comp!cx tightly coupled systems; I' '
mted the retrospec. instead,it favors "do-it.better" recemmendations. But accidents lie fallow in i- l or. So widely ac- the system itself, waiting for an unlikely concatenation of events to give q
>r_ Energy referred-to [, ] j
/,19 October 1979, egerce birth.
e g
+ i t&tionalShortcomings
- y indicators were in- Ttt final failure signaled by the report is institutional failure-presumably
'o i
/ nearby controls; the a wide range of organizational or bureaucratic features and the culture of the -j
- tl
.entually by an hour industry, including its regulators. The commission's recor.mendations on this 'j" l s filling with experts; issue were extensive. Except for some restructuring of the top echelon of the ;
uddenly inoperative. NRC and the NRC's place in the federal bureaucracy, however, they were j;if . {
.y in training" seems very general recommendations indeed. Examples of suggested changes for the bI l of an accident even if NRC are (in the words of the report) to: assure sufficient communication: '
strengthen staffs; improve capabilities; assure that safety is a first priority;
.h the many things that i upgrade licensing functions; strictly test operators; meresse safety research; d'j l fore; none was cata- j enforce higher organizational and management standards for utilities; set ,{ -l
- e events in complex,
-(
deadlines; require periodic and systematic reevaluation; create meaningful as are incomprehen- '
opportunities for participation; resolve safety issues early and meaningfully; egardlessof training). conduct systematic assessment (of almost everything); clarify instructions;
.ts and there will be '
improve inspection and auditing; and perform periodic, intensive, and open
, reviews (pp. 61-67).
as the major cause of ! Despite the generality of the recommendations, not all commissioners j the hearings) demon- ,
agreed on them. Commissioner Thomas Pigford, a professor of nuclear engi- + -
im design and equip- neering who has worked in the industry, wrote a lengthy minority report pre-s, plant designs, and j senbing less interference in the industry by government and arguing that '
ly inadequate control l nuclear power had not been proven unsafe at TMI
..ferences,and ftports Industry need not worry if the record of other regulatory agencies is a -
ustry. The most '
guide. Repeated criticisms of the Federal Aviation Administration (FAA) es and Space have neither averted air disasters nor financially wrecked the industry. Gov-that operators work .f ernment regulation has failed to impose either significant burdens or signiq.
shibited ingenuity in ', cant safety concerns on truck and rail transport, dam construction, biologi- -
iemade supplemental cal laboratories, or the manufacture of toxic chemicals. When the Occupa-s so haphazardly dis- l tional Safety and Health Administration (OSHA) tried to require warning the NRC. Operators : labels that specific chemicals used by workers are caremogenic, industry suc-adequacies and com. l cessfully resisted. The most famous recent case is that of the Food and Drug Administration (FDA). IAng passive, it recently mitiated and proposed a an operator machine I series of regulations governing the advertisement of sweetened cereals on systems of this com- children's television programs, improved product standards and certification,
{
apment, designs, and and an investigation of the insurance industry. Alarmed a Senate committee control are unlikely unanimously approved a bill halting action in these area . Perhaps the mem-
' ort refrains from en- bets of the president's commission suspected that their worthy recommenda.
Iel g
? 1 4*.:
i M Charles Perrow ',
I tions would have little effect. Indeed President Carter's response was to re.
ject their most important one-to replace the five coequal NRC commis-sioners with a single administrator. 'l l; ,
l Apart from criticisms of the NRC the commission also cited institutional
,: shytco'mings in the nuclear industry, which must " dramatically change its
' atfitudes toward safety and regulation" (pp. 68-69). As regards particular
, fsEstes, the commission was not ver) ready to make advances. The report ;
,' stated that the utilities and the supphers (such as Babcock and Wilcox) 9
- should
- establish appropriate safety standards; systematically gather, review, .
and analyze operating experiences; plan to make changes with respect to a l l 3 realistic deadline; integrate management responsibilities; clearly define roles ,'
! j' and responsibilities; attract highly quahfied personnel: devote more care and
!. attention to plant procedures (provide clear and concise wording, clear for-
.; mats, practical procedures, etc.); and establish deadlines for resolving safety ,
t ; issues. There was also a veiled reference to the interaction of safety and t
utility rate bases that somehow should be considered by state government. -
l
[,~ The training recommendations were equally vague und included,again in the i
- i commission's words
- high standards; periodic review; comprehensive ongoing j ji training; integration with experience; more fundamental understanding; etc. '
j , ,
(pp. 70-71). Fortunately, the recommendations regarding equipment were *
" j pi, more specific but pertained primarily to TMI: They contained a list ofeight 1 p major areas of inadequacies, a call for more momtoring of equipment and additional research, and an expression of concern about the massive and dan-
, Ip L gerous cleanup. j
.r j
' li-[4 Conclusions
.1l1
- A. i
- ;, Most of the commissioners were critical of the performance of the utility
,, j ,
and the NRC. Yet they resisted two conclusions: first, that it is in the nature y ,
! "s(h'i of large, complex organizations to be inefficient and to lack standards, cons- g ,
} h' munication, sufficiently qualified personnel, as well as an overriding concem M p'i for safety. Such a conclusion would force us to question whether we should g; allow systems whose risk potentials are catastrophic to proliferate in the hope
[,y 1 ,
l
, that they will be unlike other large organizations. The second conclusion ; ,
about which they demurred was that if the industry was to continue to gen-
- l L: erate catastrophic risk potentials-that is, to continue to operate-a whole- ,
I' sale restructuring of the industry (and not a moderate restructuring of the j 7
i NRC alone) would be required. Because the incentive for private profit must a i conflict with safety (at least in the short run), that incentive should be re- ;
I i
! , moved. Safety in high risk systems is so demanding a goal that to combine it ;
! with a goalof private profit almost guarantees a serious compromise. Another !
l possibility is to detach the generation of nuclear power from the utilities l}
-l I
- b u j Fi 1 ., -
4
_i I '
t s ~ - _____ - - -L- - - -
_ ~. -
haples Perrow The President's Commission and the Nomal A ccident i83 .,
.t 1se was to re- that transmit and sell it, which would be consistent with the commission's ! !
! NRC commis- goal of "the improvement of the safety of ev.isting and planned nuclear I power plants"(President's Commission 1979, p. 4).
[ f stitutional stead, the commission limited itself to the warning that "unless portions .
!!y change its rds porticular of ingry and its regulatory agency undergo fundamental changes, they j' w veritime totally destroy public confid:nce and hence. tirey will be re- ,
l :s. The report j spo bl8for the elimination of nuclear power as a viable source of energy '
and Wilcox) (Pre'sident's Commission 1979, p. 25). The prospects for such fundamental ather, review, changes seem remote, and thus the commission's recommendations seem in-a respect to a effective. Even a mildly critical reference to the Atomic Industrial Forum-y define roles an industry trade group,and the only one men:ioned-drew an angry rebuttal ;;
more care and Ung, clear for.
i from Commissioner Thomas Pigford in his minority report. During the hear. -j' esolving safety 4
ings Commissioner Patrick Haggerty was distressed by the way the utility was '(,
being run, but when the report was being drafted he repeatedly cautioned the ?
i of safety and other members of the commission that no industrial plant maintains every-te government. thing in optimum condition. Commissioner Lloyd McBride, president of the h ed, again in the United Steelworkers of America, was also reluctant to support measures that [
oensive ongoing might slow down the production of nuclear energy and the economy. H 1 erstanding; etc. The institutional failures cited by the commission involved neither the 4uipment were i structure of the industry,the role of profits in relation to high risks,the pros- j l d a list of eight equipment and pects for efficient regulation when so many interests are vested, nor the alter- it natives to these risky systems, but rather the attitudes toward safety of the ussive and dan- industry and especially the NRC.It might be argued that such things exceeded the commission's mandate; but the commission did interpret its function broadly when it debated and voted on moratoriums and made recommenda-
- tions about'the siting of future plants, the licensing of nearly completed j
, plants, new industry groups, and so on. The commission expanded its man.
, .
- of the utility date but stayed within its policy framework. The report is as forthright and the nature l concrete as any we are likely to get from a presidential commission, and it i ndards, com- '
will undoubtedly lead to some improvements. But it stopped short of recog-
- riding concern 3 nizing that a nuclear-power system is inherently prone to normal accidents re-ther we should gardless of our efforts, and some accidents may be worse than TMI. Instead, k ate in the hope the commissioners blamed the NRC, the utility, and the operators. Even if ',
'nd conclusion , all their recommendations are taken seriously by industry, we will still have ;
antinue to gen. ; tightly coupled complex systems whose potential for catastrophe is enormous. i crate-a whole- i 1
..cturing of the h
. ate profit must y a should be re- References .i t to combine it mmise. Another
.\iason, John F,v' 1979 The Technical Blow-By-Blow. IEEE Spectrum 16. November:
y un the utilities d 33-42. p
-s i 7
e .
g
4 i *
! 184 I Charles Perrow i
jJ '
Perrow, Charles 1979 TMI: A Normal Accident. In SocialSd rce Aspects of the Aeci.
I dent at Three Afile Island. Report prerated for the President's Commission on the Accident at Three \ lite Island. New York:
k Social Science Research Council.
dent's Commission on the Accident 1t Three ? file Is!and
. a1979 The Need for Change: The Legacy of T.1l1. Report of the com-I mission. Washington, D.C.: U S. Government Pnnting Office.
1979 Closed Hearings of the Commission,15 September 1979.
1979 Public Hearings of the Commission, 30 and 31 May,18 and 19 i July 1979.
Il j'
Rubenstein, Ellis 1979 The Accident That Shouldn't Have Happened.IEEESpectrum 16,
~
November:33-42. I
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