Thirty-years after Three Mile Island: Why the Kemeny Report is Still Important

Why the Kemeny Report is Still Important
Thirty-years after Three Mile Island, we still don’t understand it!

For the past thirty-years, there has been no nuclear construction in the U.S. Today we stand on the threshold of a nuclear renaissance. Before we resume where we paused thirty years ago, we should reexamine why construction halted – what were the problems? Why did the U.S. go into a commercial nuclear hiatus? Let’s look again at what happened.

In the early morning hours of March 28, 1979, in Middletown, Pennsylvania, a condensate pump tripped at a nuclear plant – a minor event. Moments later, other alarms began ringing, signifying the event’s escalation. An accident was starting to happen. Within several hours, the unthinkable had occurred – Three Mile Island’s (TMI) highly-radioactive nuclear reactor core had partially melted. Radioactive fission products were loose inside plant primary circuits, and no one knew what caused it. Within several hours, the operators declared a general plant emergency, putting the whole state on alert. Engineers, managers and regulators alike swarmed to the site’s control room to try to understand what happened. Frantically they sought to fix whatever was wrong, only no one knew what was wrong – only that fuel was failing. Critical core cooling was inadequate, releasing fission products into the primary coolant.

Several hours after the initial event, operators finally restored primary cooling, mitigating further core damage – the accident was over. However, by that time half of the core had melted! For the next several days, confusion, alarm and panic ebbed and flowed from the control room. The press sought to report what experts wouldn’t admit or didn’t understand. Once it was over, nuclear power had lost credibility and along with it, public support. TMI did not take a single life, despite its financial cost and mental stress. However, the public distrust left in its wake helped cancel or abandon sixty nuclear projects across dozens of states. By costing investors and the public billions of dollars, financial lenders imposed a virtual moratorium on nuclear power development.

Following the accident, President Jimmy Carter asked Dartmouth President John Kemeny to chair a commission to independently investigate TMI, its causes, participants, their effectiveness, and make recommendations. Twelve highly educated people neither for nor against nuclear power comprised the Kemeny Commission. They represented different interests assessing the industry from the outside. The Commission delivered its findings October 30, 1979 in the Kemeny Commission Report – an assessment of the events, causes and recommendations. The following week Time Magazine called the Commission’s report a “Scathing Look at Nuclear Safety.”

To prevent nuclear accidents as serious as Three Mile Island, fundamental changes will be necessary in the organization, procedures, and practices – and above all – in the attitudes of the NRC … and the nuclear industry.

Predictably, the report caused public controversy. The Kemeny Commission called for changes at the NRC, and in the nuclear industry itself. No utility would order new nuclear units in the U.S., and they would cancel 60 of the 165 units ordered.

So too, the Nuclear Regulatory Commission (NRC) initiated investigations. The NRC appointed a TMI Task Force, which developed specific recommendations “Lessons Learned”. It also hired an independent investigator, Rogovin, Stern & Huge, who reported their findings in the Rogovin Report. While NRC’s task force focused on events and their causes – equipment or process failures, it didn’t address organizations, institutional beliefs or structural problems. However, the Kemeny Report did.

For thirty years, the Kemeny Report has been silently on the shelf. We still don’t understand its basic issues, lessons, and recommended changes. Without understanding them, we can’t move forward confidently in a nuclear renaissance. Without confidence, people will question nuclear power and those who use it.

What did the Kemeny Report say, then? What were its conclusions and recommendations? Well, Kemeny found problems centered around fundamental principles, so the irony was problems were so common. Kemeny found weaknesses that were anything but new – many large organizations have them. However, nuclear energy’s higher risks gave its recommendations a greater urgency. Although the NRC and industry have addressed many recommendations, some remain. Of the forty-four basic recommendations cited by the President, five broad categories emerge:

• Technology arrogance
• Organizational culture
• Making requirements “actionable”
• Focus on the “Big Picture”
• Ability to learn

Let’s look at a few of these more deeply, relating them with the past.

Technology Arrogance

Complex processes and jargon that obfuscate are fundamental nuclear technology weaknesses. At TMI, engineering overconfidence ultimately led to lapses in design accountability. Preoccupation with complexity was common, lacking internal controls. Isolation lets nuclear experts think their understanding is complete, though it is not. Where ignorance leads to complacency, unquestioning mindsets undercut nuclear safety. The industry still lacks common standards and certifications for processes. Anyone can call himself a nuclear engineer, even those without credentials. Nuclear organizations give engineers without degrees or licenses titles. Unrestrained complexity continues to control nuclear processes today, as it did thirty years ago.

Organizational Culture

Not all organizations can apply nuclear power technology successfully. Some lack attributes necessary for nuclear safety, like objectivity or accountability. Kemeny cited NRC oversight for tolerating ineffective industry practices. People, skills, ability to examine technology objectively, sustain open-minded perspective and challenge assumptions all remain nuclear issues. The nuclear industry isolates people. The industry has been slow to accept superior technology like digital controls, rotary air compressors or computer-based design basis integration. These have been available for decades now, yet U.S nuclear power still doesn’t use them. U.S. nuclear power plants today are virtual museums of obsolete 1970’s processes and technology.


Making Requirements “Actionable”

Failure to recognize that a stuck-open power-operated relief valve would create a small line break “loss of coolant” accident epitomized failure to translate design basis accurately into operations. While any number of things -- inadequate reviews, operating requirements translation, inadequate testing – could have caused the TMI problems, the NRC cites similar near-miss close calls regularly. Events that recur over and over repeatedly have a systematic basis. However, NRC regulation eschews modern quality processes that identify, examine and correct systematic process weaknesses. Oversight bodies that reject the use of quality processes to get better practically block those it regulates from applying similar ideas. Converting nuclear plant designs into “actionable” operations tasks eclipses NRC experience – after all, it’s not an operating organization, unlike utilities or architect-engineers. By not understanding operating practices like how to develop and improve processes, NRC compromises the nuclear industry safety basis.

Focus on the Big Picture

Operating excellence takes follow-up on problems. Understanding overall requirements and how individual tasks contribute to overall requirements allows follow through. TMI allowed mindsets like, “Let someone else take care of it – it’ll be okay,” or “It couldn’t possibly happen to us – it never has before,” or “It’s too hard to change, with all the rules and procedures,” or “We meet NRC requirements already, that’s good enough.” Many other rationalizations met formal requirements in rules without understanding their basis. Kemeny said that’s what led to TMI’s operating weaknesses. Absence of effective measures to maintain defense-in-depth and the “people safety system” stemmed from failure to understand and focus on the big picture – overall requirements, on multiple levels. Accepting things as they are, excluding questioning attitudes exudes the very complacency TMI represents. Similar mindsets prevail in the nuclear industry today.


Ability to learn

Nuclear industry professionals and organizations couldn’t see ineffective processes, obsolete equipment or problems people had understanding nuclear technology. On the other hand, Kemeny members outside the system could. TMI lapses in understanding were evident to those who looked, but it took outsiders and a near-disaster to question practices that had long been taken for granted.

The nuclear industry today remains focused inward, just as Kemeny left it. It still can’t grasp lessons from the past or others, including its non-nuclear counterparts. It will not introduce new technology into its nuclear environment. Furthermore, intrinsic learning limits imposed by regulatory mindsets – avoiding new, different, or untested or untried methods from outside the industry – has left an industry replete with obsolete controls, equipment and – worst of all – mindsets. It struggles simply to replace obsolete equipment as time passes.

The Kemeny Report cites oversight for imposing barriers to finding and fixing problems. Focus on meeting the letter of the law, not its safety intent, led to weaknesses that eventually compromised the “safety system.” At TMI, people stopped actively thinking when they came to work. Nuclear mindsets today have hardly changed.

While the industry has addressed some Kemeny findings, others still remain. Alternatives can address a concern without using the recommended solution. For example, while the Kemeny Report suggested one NRC commissioner, President Carter left five, opting instead to strengthen the Chairman’s role. Otherwise, the President accepted all forty-four (44) Kemeny Commission recommendations. More urgently, we should ask: How did nuclear regulations get where they are today? Is the framework today adequate and effective? Can the NRC be effective fostering improved nuclear technologies? Can the NRC sustain the U.S. through the next nuclear design generation in its current form?

Kemeny wasn’t the first to question NRC effectiveness, and hearing concerns voiced in the Senate won’t be the last. Did the tradition of regulating the nuclear industry from the outside evolve just by accident? How can those unfamiliar with nuclear power operations ultimately serve the public’s health and safety interest?

Kemeny member Governor Bruce Babbitt's concluding remark echoes across three decades:

"While this [Kemeny] Commission has clearly addressed the institutional shortcomings of the NRC in its recommendations, it has not addressed the institutional problems of the industry."

Kemeny could identify critical problems, but others would need to address them. Critical questions remain, today. NRC’s added many complex new rules and requirements since TMI. Yet the complexity Kemeny found that contributed remains pervasive within the regulatory framework. Non-actionable guidance abounds. The Institute of Nuclear Power Operations (INPO) and Nuclear Energy Institute (NEI) have foregone their development roles to improve the framework, training or design basis methods, waiting for NRC guidance. Industry ignores technical developments from other industries, believing it can advance no further without NRC direction. Industry tolerates technical obsolescence – like forty-year old analog controls. Most disconcerting, industry awaits for NRC to direct changes, rather than initiate necessary changes on its own. Ironically, this lack of initiative was the very essence of complacency identified in the Kemeny Report.

An ineffective framework won’t support light water reactors effectively, much less new reactor designs using different technologies. Without changes, we can resign ourselves to repeating the same evolutionary learning mistakes in new designs as we made in the past – the very errors that created TMI. We can continue to tolerate near missies like Davis- Besse and Palo Verde, berating licensees all the while for their operational lapses. Meanwhile, design reliability assurance programs from nuclear suppliers are on hold. To sponsor ever-more complex technical requirements like PRA applications , we must balance that with implementation. We must carry requirements through rather than ignore them, hoping they happen like we did at TMI. Thirty years ago, the Kemeny Commission said the nuclear industry needed to address institutional problems. Isn’t it time we did? Either we use the Kemeny findings, abandon nuclear power – or place ourselves at risk for another accident like TMI.

Irony: Looking Back on Thirty Years: Senate Hearing on Nuclear Safety Complacency and Lessons Learned

April 3, 2009


Honorable Senator Thomas A. Carper
Chairman, Senate Environmental and Public Works Subcommittee on Clean Air and Nuclear Safety
United States Senate 513 Hart Building
Washington, DC 20510

Three Mile Island Looking Back on Thirty Years: Senate Hearing on Nuclear Safety Complacency and Lessons Learned
(Hearing March 24, 2009)
Senate Webcast: rtsp://video.webcastcenter.com/srs_g2/epw032409.rm?start=17:20

Dear Senator Carper:

March 28, 1979, undercooling damaged Three Mile Island Unit 2’s reactor. Events came to be known as “Three Mile Island,” or simply “TMI.” While the hearing’s general review of lessons learned and safety improvements since TMI was ad hoc, Senators asked several substantive new questions: “What do we still need to do to avoid nuclear safety complacency?” and, “Can we improve nuclear license process duration, maintaining safety? Must design reviews licensing new Light Water Reactors (LWR) plants take five years or longer to safely complete?”

The nuclear industry has been lethargic deploying current technology. Digital controls remain unapproved for nuclear use today. Slow progress approving digital controls demonstrates performance failure. When nonperformance becomes the norm, Senate oversight should challenge agencies to find better ways to get the job done.

In its commemorative hearing March 24, NRC failed to answer several substantial Senate’s Subcommittee questions. For example, whether new plant license reviews could be shortened while maintaining safety was not answered.

Interviewees failed to answer Senators’ questions completely. Some failed to address some questions at all. To avoid complacency, restore candor in nuclear dialogue and regain public confidence, we must demand, like Admiral Rickover -- “Answer the question, please!”[1]

As follow-up, the Senate EPW Clean Air & Nuclear Safety Subcommittee should ask the NRC's commissioners to:

• Defend current safety improvement processes.
• Review safety performance with continuous process improvement methods[2]
• Review the new licensing process implementation method for overall effectiveness
• Engage those able to independently assess nuclear performance using continuous improvement methods
• Establish a safety review licensing timeline based on substantial content milestones
• Pilot an NRC continuous improvement process like the US Department of Commerce Baldrige application, proven in use by other federal agencies .

Sincerely,

J.K. August, PE
J.J. Hunter SRO
CORE, Inc.
303-425-7408/970-330-1411
Attachment: Senate Response to Hearing Review
Re: EPW CA& NS Hearing Three Mile Island: Thirty years looking back

[1] Actually, it was -“Answer the question, dammit!” Evasive, incomplete or specious responses inflamed the Admiral, causing him to ask, “Do you really want this [nuclear] program?” He followed that shortly by shouting his legendary dismissal, “Get the h…out of my office, you horse’s ass…”
[2] The Armament Research, Development and Engineering Center, US Army Picatinny, NJ. (ARDEC) The “home of American firepower” won the US Department of Commerce Baldrige Award in 2007. "Lean 6-Sigma” is another process improvement approach approved by DOD. All have common elements.