[A Brief Invited Position Paper for the Conference From Chernobyl to Nuclear Safety in Eastern Europe and Newly Independent States: The Search for a New Partnership]

Paris, May 22-24, 1996

A Major Cause of the Chernobyl Accident: The Vital Role of Human and Organizational Factors in the Safety of Nuclear Power Plants

Dr. Najmedin Meshkati
Associate Professor & Associate Executive Director
Institute of Safety and Systems Management
University of Southern California
Los Angeles, California 90089-0021

Tel: (213) 740-8765 Fax: (213) 740-8789
Email: meshkati@usc.edu

"I advocate the respect for human engineering and sound man-machine interaction. This is a lesson that Chernobyl taught us."
The late Academician Dr. Valeri A. Legasov, the First Deputy Director of the Kurchatov Institute at the time of the Chernobyl accident, and the head of the former Soviet delegation to the Post-Accident Review Meeting of the IAEA in August, 1986 (1).

"The Chernobyl accident illustrated the critical contribution of the human factor in nuclear safety."
The International Atomic Energy Agency's (IAEA) Nuclear Safety Review for 1987 (p. 43).

"The root cause of the Chernobyl accident, it is concluded, is to be found in the so-called human element....The lessons drawn from the Chernobyl accident are valuable for all reactor types."
IAEA's Summary Report on the Post-Accident Review Meeting on the Chernobyl Accident (INSAG-1, 1986, p. 76).

"The (Chernobyl) accident can be said to have flowed from deficient safety culture, not only at the Chernobyl plant, but throughout the Soviet design, operating and regulatory organizations for nuclear power that existed at the time...Safety culture...requires total dedication, which at nuclear power plants is primarily generated by the attitudes of managers of organizations involved in their development and operation."
The IAEA's International Nuclear Safety Advisory Group (INSAG), The Chernobyl Accident: Updating of INSAG-1 (INSAG-7, 1992, p.24)

"For us, the indisputable lesson of Chernobyl lies in this: the principles regulating the further development of the scientific-technological revolution must be safety, discipline, order, and organization. Everywhere and in all respects, we must operate according to the strictest standards."
Mr. Mikhail Gorbachev, General Secretary of the Central Committee of the Communist Party and President of the former Soviet Union, in the wake of the Chernobyl accident (2).

The critical role of human and organizational factors-related causes in the Chernobyl accident is captured in the foregoing statements and addressed, either directly or indirectly, by a few other studies (3). The research has demonstrated that the safety problem of the nuclear power plants lies in their human and organizational factors, such as operator error, training, and management style (4). In fact, human performance should be of vital importance to the reliability of nuclear installations around the world; a 1985 U.S. Nuclear Regulatory Commission study of Licensee Event Reports suggested that upwards of 65% of U.S. commercial nuclear systems failures involve human error (5). Therefore, the way we operate and regulate these technological systems should be given equal (or even sometimes more) priority as to the other 'technical' or hardware-related considerations. Unfortunately, the human and organizational factors are complex, not so well-understood, and unlike hardware or equipment problems, there is not a 'quick fix' for them. Stopgap measures such as blindly resorting to 'technical fixes' and throwing more automation at the problem (as suggested by many), or developing more reactive regulations would not present any sensible solutions. Without careful analysis of the impact of these measures on the other components in the nuclear power plant system, we will aggravate the problem by suppressing and convoluting the real issues.

The dormant, inherent safety problems of many nuclear power plants in Central and Eastern Europe are analogous to the 'resident pathogens' within the human body, which combine with various triggering factors (e.g., stress, toxic agencies) that could bring about a disease. Some of these plants have not failed yet, probably because either they have not been given enough time, or because the concatenation of events needed for any failure, has not yet occurred. Due to the complexity and unknown nature of these safety pathogens, conventional safety practices are no longer capable of offering effective prognosis. Possibly, either their effectiveness may have reached a saturation level, or safety in this context, i.e., a field of science and practice, needs an overall paradigm shift in dealing with nuclear power technology and operation. Nevertheless, safety personnel of these plants (and countries), like small town physicians trying to diagnose and cure AIDS, are neither equipped nor in a position to solve the problem individually, no matter how educated or how dedicated they may be. They need to tackle it collectively with an institutionalized approach and share their findings. Nuclear safety specialists in Central and Eastern Europe need a supporting, centralized think-tank research staff to unravel the unknown, develop implementation policies, and disseminate findings. This, of course, is a collaborative effort which needs active participation of the nuclear safety community in the West.

There have been a lot of reports about Chernobyl's consequences. However, one of the most important implications of this accident has not been addressed yet: the critical status of the 58 other former Soviet-designed reactors, including 15 Chernobyl-type (RBMK) which are operating in Central and Eastern Europe. With the exception of the two reactors in Finland that have Western-style safety features, the rest desperately need help and there is neither a cohesive plan nor an institution for it. For instance, Dr. Alexei Yablokov who chairs the ecological safety commission in President Boris Yeltsin's Security Council and works as his counselor for ecological affairs, has stated that all the commercial nuclear reactors operating on Russian territory are nothing better than "bombs temporarily generating electricity" (Los Angeles Times, June 13, 1992). These reactors' share of energy generation in their respective countries is rather significant. For instance, 2 units at Ignalina plant in Lithuania produce 80% of the country's electricity. Thus, in the short run, their closure and replacement are neither realistic nor economically feasible.

Another worrisome former Soviet-designed reactor is under-construction at Juraguá plant in Cuba, some 200 miles from American shores. It is an updated version of the VVER-440 reactor, which is similar to some Eastern European ones, with a power rating of 675-megawatt. A U.S. General Accounting Office report in September 1992 highlighted major safety concerns such as poor construction practices and inadequate training for future reactor operators.6 According to a recent article in The New York Times (February 25, 1996), a recent study by the National Oceanic and Atmospheric Administration calculated that within four days of an accident at Juraguá, radioactive fallout could be carried as far west as Texas or as far north as Washington, D.C.

There will, undoubtedly, be a lot of interesting reports about the aftermath of the Chernobyl accident around April 19-26. However, I would like to make sure that the legacy of Chernobyl and its implications for the foregoing 58+1 reactors are not ignored. If the lessons of Chernobyl and the efforts for improvement of the foregoing 58 plants were to be clearly delineated for the world's people and opinion leaders, then a productive and positive atmosphere would be created. This is a necessary condition for international cooperation and will pave the way for the West to play an active role in these efforts.

Although accidents are always tragic and can have devastating effects, there are many lessons that society and industry can learn from them. As notable American philosopher William James has said, "great emergencies and crises show us how much greater our vital resources are than we had supposed." We can and should be able to utilize our vital resources to operate nuclear power plants safely; we do not have a choice in the short run. However, we need an overall paradigm shift in dealing with nuclear plants design, construction, operation, and regulatory oversight. In order to improve the safety problems of nuclear power, we need to improve the safety culture of this industry and proactively address human and organizational-related factors. We need a total system analysis of the whole nuclear power plant's system by concentrating on its three main composing sub-systems; human, organizational, and technological. To keep the nuclear Genie bottled around the world, we need genuine international cooperation and coordination among equipment manufacturers, operating companies, operators' unions, regulatory agencies, international organizations, scientific and research communities, and affected governments.

(1). Quoted in Monipov, V.M. (1992). Chernobyl operators: criminals or victims? Applied Ergonomics, 23(5), 337-342 (page 340).

(2). Quoted in Illesh, A. (1987). Chernobyl. New York: Richardson and Steirman, Inc (page 177).

(3). Meshkati, N. (1991). Human Factors in Large-Scale Technological Systems' Accidents: Three Mile Island, Bhopal, Chernobyl. Industrial Crisis Quarterly, 5, 133-154.

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(4). Perrow, C. (1984). Normal accidents. New York: Basic Books, Inc.

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Meshkati, N. (1992). Ergonomics of large-scale technological systems. Impact of Science on Society [The United Nations Educational, Scientific and Cultural Organization (UNESCO) Journal; published also in Arabic, Chinese, French, Portuguese and Russian], 165, 87-97.

Meshkati, N. (1994). The critical role of ergonomics in ensuring the safety of nuclear power plants around the world. Proceedings of the 12th Triennial Congress of the International Ergonomics Association, Toronto, Canada (15-19 August), Volume 5, Ergonomics and the Workplace, 1-3 (ISBN 0-9698544-4-7).

Meshkati, N., Buller, B.J. and Azadeh, M.A. (1994, August). Integration of Workstation, Job, and Team Structure Design in the Control Rooms of Nuclear Power Plants: Experimental and Simulation Studies of Operators' Decision Styles and Crew Composition While Using Ecological and Traditional User Interfaces. Volume I. Grant Report Prepared for the U.S. Nuclear Regulatory Commission (Grant # NRC-04-91-102). Los Angeles, California: University of Southern California.

Meshkati, N. (1995). Human factors in process plants and facility design. In R. Deshotles and R. Zimmerman (Eds.), Cost-Effective Risk Assessment for Process Design. New York: McGraw-Hill, 113-130.

(5). Wells, J.E. and Ryan, T.G. (1991). Integrating human factors expertise into the PRA process. In G. Apostolakis (Ed.), Probabilistic Safety Assessment and Management. New York: Elsevier, 577-582.

(6). The U.S. General Accounting Office (GAO) (1992, September). Nuclear Safety: Concerns about the Nuclear Power Reactors in Cuba. Washington, D.C.: GAO (GAO/RCED-92-2620).