What have we learned from Three Mile Island 17 years later; Implications for future Chernobyl(s).

Patra Shovityakool

Shovitya@scf.usc.edu

ISE 370L

1996

The Three Mile Island accident in Pennsylvania and the Chernobyl accident in Belarus should have taught us of how destructive lives can be if our today technological systems go wrong. Although we receive many benefits from our today advanced science and technology, we must realize that there are negative aspects of what the technology can bring us as well. The effects of the two accidents are much more than humans can afford. People tend to think of these two accidents as some "snapshot photos" of fire and explosion. In fact the effects of these accidents widespread through out the world and will last longer than most people can imagine.

The Chernobyl tragedy should have never happened if we took the Three Mile Island incident, which occurred 17 years prior to the Chernobyl one, seriously. Nobody knew where Chernobyl was before the accident took place. As the result of the massive explosion on April 26, 1986, Chernobyl suddenly became the world's foremost symbol of technological disaster together with the Three Mile Island.

There are many contributing factors that possibly lead to the accident, such as the human error, ineffective training, non responsive managerial system, poor communication between departments, but the most important factor is the safety issue. According to Shcherbak, Scientific American, (April 1996, P.44), on the night of the accident, the operators were conducting a test to see how long the generators would run without power. For this purpose, the power was greatly reduced, and blocked the flow of the stream generator. Unfortunately, the RBMK1000 has a design flaw that makes its operation at low power unstable. Three second later, massive explosion occurred, and massive amount of radiation emitted to the environment. Radioactive particles were carried by wind and landed on different areas as far as thousands of miles away. According to Schcherbak, Scientific American, (April 1996, P. 45), the destroyed reactor liberated hundreds of times more radiation than was produced by the atomic bombings of Hiroshima and Nagasaki.

The Chernobly has both physical and psychological effects on people. Cancers caused by radiation can take decades to detect. Many physical disorders are detected among children who were exposed to the radiation from the explosion. Lands, crops, and water are contaminated. People were forced to evacuate their homes because the land became inhabitable. Many innocent lives were involved in this tragedy as the result of the technological failure. The cost of cleaning up the Chernobyl mess is beyond our capability. We are not able to cure all the people who became sick as the result of radiation expose. We cannot pick up every soil particle, air particle or water molecule to clean out the radioactive particles. But we can take a step forward and learned from our mistakes.

Lack of adequate and shared information was the one of the contribution to the cause of an accident. Many organizations are divided into two parts, the management and the workers. The management part only cares about making profit, and the worker part cares more about the safety issues. There was a scandal that the Northeast Utilities fired any worker who dared to raise the safety concerns. Communication within the plants between the management level and the worker level is very poor. The top level management does not take the workers' concerns into account. The Northeast Utilities focuses more upon the economical benefits than with ensuring the public safety.

Money VS Safety has always been a hot topic in any business including the nuclear power plants and politics have always been the major influence of the decision. In order to save the budget, safety regulations are often violated. The less investment money required means more profit for the plants and more bonus available for the workers. According to Pooley, Time magazine, (March 4, 1996, P. 48), by sidestepping the safety requirements, Millstone saved about two weeks of downtime for each refueling during which Northeast Utilities has to pay $500,000 a day for replacement power.

Though the NRC is the one who is responsible for inspecting the safety of the Northeast Utilities, the NRC helped the Northeast Utilities to get by with some violations.

According to Pooley, Time magazine, (March 4, 1996, P. 52), safety reports made it clear that both on-site inspectors and officials from the NRC's Office of Nuclear Reactor Regulation had known about the full-core off-loads since at least 1987 but had never done anything about them. Nuclear regulations are not only the power plants' and the NRC 's concerns, but it is also the public's business. Nobody wants another Three Mile Island or the Chernobly tragedy happen again. If what is going on within the Northeast Utilities is not revealed to the public, it is possible that the Northeast Utilities might become another technological disaster some day.

Today the number of nuclear power plants is growing all over the world. There is an ominous potential for an accidents like the Accidents like Three Mile Island and Chernobly can occur again anywhere. The interactions and communications of the different levels within the organization and the technological system itself determine the safety effects of the plants. Future Chernobly(s) will not happen if we begin to take safety issue seriously together with a reinforcing strict safety regulations worldwide.

________________________________________________________________________

Date: Mon, 8 Apr 1996 08:01:58 -0700 (PDT)

From: Richelle

To: meshkati@bcf.usc.edu

What have we learned from Three Mile Island 17 years later ?

Implications for future Chernobyl

Richelle Filipina

email : filipina@chaph.usc.edu

ISE 370L

1996

For the past years, major accidents have contributed to our awareness in the nuclear power plant surrounding us. These accidents have set an example

to us on how we should view or look at the safety features of a nuclear power

plant. There are many aspect that one must take in consideration, for example

the lack of human factor.

Today, Nuclear power plant is one of the source that is available to

generate electricity. Currently, According to the International Atomic Energy

Agency, " there are 428 nuclear power plants operating in 26 countries, 12 of

which went on line last year " (Meshkati 1989). Because there have been an

enormous demand for electricity the demand for the nuclear power plant have

increased all over the world. With this in mind, people should questioned their

capabilities and safety.

Chernobyl and Three Mile Island are two major accidents that happened

that made the whole world realized the odds that we are up to. Chernobyl was

one of the worst technological environmental disaster. The aftermath of this

accident can be felt not only in Chornobyl but also in the surrounding

countries such as Belarus, Russia, Georgia, Poland, Sweden, Germany, Turkey,

and as far as Japan and US. According to Shcherbak, " in the immediate

aftermath of the explosion and fire, 187 people fell ill from acute radiation

sickness, 31 of these died " ( Shcherbak 1996). About 300,000 deaths have

accounted for this accident. (The Economist, April 27, 1991) Cancer rates

have increased enormously among children specifically there have been seven

different thyroid cancer . (Specter 1996) Because of these effects and

damages, we must take a closer look at the nuclear power plant that exist

around us. Human factor plays an important role in Chernobyl and Three Mile

Island accidents. According to Meshkati, " these incidents are caused by a

combinations of many factors whose roots can be found in the lack of human

factor " (Meshkati 1991).

One of the human factor that have caused these accident is at the

design stage. In this area, the control room must be properly designed.

Controls, switches and display must be consistent and should be placed at

the appropriate places. Displays should be easily read. In the Three Mile

Island, this factor has one of the cause that led to the accident. Because

there was no indicator in the Pilot Operated Relief Valve. You could not tell

whether the valve was open or close. In addition to this, there was no

indicator on the exact water level of the reactor core which made it more

difficult for the operators. The second factor, is the lack of training of

the operators. Most of them are not properly trained to withstand pressure or

work in emergency. (Meshkati 1991). Another factor is the interaction between

management and the organization. Some management just ignores whatever their

employee's complain them. They do not pay attention to the most important

detail that they must know. According to Kerber, some employee's have been

fired because they raise the issue of safety. (Kerber 1996)

Chernobyl and Three Mile Island have taught us a lesson about the

tragic disaster it caused the nation. Knowing these facts, are we still

willing to gamble what is at stake ? How many more lives do we have to

destroy to realized that there is something wrong. If we value life and

if we think life is precious then we should make a move and make a difference

to make this world a better place to live in.

References:

Kerber, R. (1996, March 11). NRC May Close Two Plants Owned By Northeast

Utilities, Citing Safety. The Wall Street Journal, A16.

Meshkati, N. (1989) No: Focus on Engineering fix still continues. Los Angeles

Herald Examiner, A17.

Meshkati, N. (1991) Human Factors in Large Scale Technological Systems'

Accidents : Three Mile Island, Bhopal, Chernobyl. Industrial Crisis

Quarterly, Volume 5, 131-154.

Pooley, E. (1996, March 4) Safety is Not First at the NRC. Time Magazine,

Volume 14 No.10, 46-54.

Shcherbak, Y. (1996, April) Ten Years of the Chornobyl Era. Scientific

American, 44-49.

Specter, M. (1996, March 31) 10 Years Later, Through Fear, Chernobyl

Still Kills in Belarus. The New York Times.

Wald, M (1996, March 9) Safety Deadline Set By Nuclear Agency For 2 Power

Plants. New York Times, A7.

________________________________________________________________________

ISE 370

Kwok Hiu Kei

Case evaluation of Three Mile Island.

What we learn about the Three Mile Island ?

Three Mile Island was the first nuclear power plant exploded in the history. In this disaster, it can tell us clearly that the dangerous of the human at control the nuclear power at the present technology and situation, it also let us to realize that the main problems of human at controlling and using the nuclear power. This accident is directly harmful to our earth, but it can also act as an alarm to let people awake from the usage of the nuclear energy and be a motivation for people In case to improve and change the present situation of the nuclear power plants found in the world.

Human error can be justify as an important factor that most disaster found in the history was directly according to the human mistakes. In the Three Mile Island case, the accident was partially cause by its unsafe and unreliable design of the reactors, but mostly was cause by the human mistakes. And these factors were important to determine the solution of the dangerous nuclear power plant. The example was the unprofessional of the operators, like in the THI case that they make a wrong perception of the signal that they did not know the true was the water temperature is high when the pressure inside the reactor is high. Then they cut the water supply and make the thing went more serious. Second, they are unknowledgeable about the nuclear power reactor's operation; when they get the warning signal from the control panel, they did not consider about the operation function of the reactor and make the decision to cut the water supply instantly. Finally, they are also lack of responsibilities; after they made the big mistake to the reactor and cause the meltdown of the base of the reactor. They did not recognize that this was the problem created by them self and made the investigation difficultly after the accident.

Besides of the factor of the human error, the old and not ergonomic designed reactor and control room take the second big problem in this accident. First, the old style systems were much more depends on the human's operation, this has a disadvantage that increases the workload and stress of the operators and increase the chance of the operator to make mistakes during the operations. Sometime the very important decisions can just decide by an individual operator. Second, the old style control panel can just provide some single signal light for a single purpose or meaning, this will make the operators easy to confuse with the indications came from the control panel. Moreover, these kinds of control panel also disperse the job within the operators and make each operator can not understand the indication from the indicator completely.

By conclude of the problem found in the old style nuclear power plants are that they also lack of the human machine interface consideration, and this can be improve by done in three processes:

First, I think the most important thing is to reduce the human error by employ more professional workers with sufficient knowledge about the operation of the nuclear power plant. These people need to train properly and teach with full knowledge about the operation process of the nuclear reactors. They also need to select from people who with high responsibilities, high logical and high diagnose abilities by the way to help them have the chance to take place in making executive decisions. On the other hand, stable emotion is prefer for the job in order to reduce the stress during the work and produce mistakes. Therefore, study of each worker's behavior and assign for suitable job is necessary. During the working period, provide periodic psychology check is good to keep them out of stress and with constant emotional. Finally, avoid the chance of centralization, divided the operation job into several branches in case to reduce the risk of human mistake that just made by one person.

Secondly, more automatic systems need to involve in the system. In the Three Mile Island case, if the accident can be detect by the operator correctly in the beginning. Then it can minimize the accident directly. According to this, introduce more automatic component into the system and redesign the layout of the plant and control panel can be very important in this case. For example, if replace the robot at doing the refueling job and set with precise time for the robot to let the fuel rod to cooling down before put into the storage pool. Then it can reduce the chance that the incorrect cooling time make by the human operator and cause the overheat of the storage pool. Besides of this, increase of the automatic involve in the work also mean it will decrease the complexity of the control panel and increase the ease of operate of the operators, as the single light indicator can be change by replace with screen and display with some meaningful sentences. Finally, shut down the system for periodic checking is very important.

The Chernobyl nuclear power plant is the most dangerous nuclear power plant in the world which I known. This is because of its reactor number four has exploded in April 1986 but other three reactors keep working in today due to the difficulty of the economical problem of the Ukraine Government. The problem of these three reactors is exactly the same as the one that has exploded and never be consider to shut down or to renew instantly, and will keep working until 2000. So if these three reactors and another 58 similar reactor are keep working under the situation of lack of human machine interface consideration. Then the next big disaster will be easy to happen soon. Thus in case to reduce this tragedy, the nuclear power plants that are under safety need to be closed or repair. Also the economy help of the national to the country who own these kinds of power plants is necessary and important.

________________________________________________________________________

Date: Wed, 3 Apr 1996 15:42:54 -0800 (PST)

From: BUCKWILD

To: Najm Meshkati

Subject: Nuclear Paper Report

MIME-Version: 1.0

The ability to contain the power of nuclear energy has been a major

ambition of world governments in the 20th century. Bombs, power plants,

submarines, etc., have all been developed and used in testing , war, and

to provide and ever growing energy need for an energy hungry society.

Nuclear energy, when harnessed safely and wisely can provide an excellent

source of power, but can ways be found to do this safely and

economically without endangering the global community and damaging our

treasured environment? Two major questions that need to be asked (and

answered) on this 17 year anniversary of the Three Mile Island nuclear

power plant accident and the 10 year anniversary of the Chernobyl

nuclear disaster are: What have we learned form these two accidents and

what does the future hold in regard to future Chernobyls?

"The Chernobyl disaster taught us there are no borders to the modern

world," said Ivan A. Kenik, the chief Belarus official in charge of the

Chernobyl aftermath. "It taught us to question faith in technology and

in ourselves. I now wonder if we as a civilization have the knowledge,

strength and wisdom to survive this nuclear century?" (Specter, 1996)

This is a powerful statement questioning the morality of continuing with

nuclear power. The principal risks associated with nuclear power arise

from health effects of radiation and environmental damage. Health

effects include: radiation burn (normally results in death), radiation

poisoning, thyroid cancer, "Chernobyl Aids" (a condition that results in

a type of white blood cells being diminished by radiation) (Shcherbak,

1996), panic, all-out hysteria, psychological damage, and many other

problems named and still yet unknown.

The environmental hazards are a bit more obvious. The land around an

18 mile radius is off-limits to everyone (unless special pass is

obtained). Chernobyl affected the whole northern hemisphere of the

world, whether it was measurable radiation findings in the US, half-way

around the world, or if it was as outrageous as the effects near the

accident. According to Dr. Najmedin Meshkati, assistant professor of

Human Factors at the Institute of Safety and Systems Management,

University of Southern California, "Within each of these plants

(referring to the over 425 nuclear power plants worldwide) lies the

ominous potential for an accident of global magnitude, one that could

produce serious health hazards, economic losses and long-lasting

environmental consequences. Chernobyl certainly taught us that. The

radioactive fallout from the damaged reactors there, for example,

contaminated the milk supply in Sicily, a thousand miles away." With

these type of hazards occurring, and many more just waiting to happen,

safety and engineering must be at it's best to prevent anything of the

sort to be a repeat of history.

Obviously, we have unfortunately learned alot about what happens when

things go wrong in a nuclear power plant. The tremendous amount of data

and facts to arise from these two tragedies is enormous. The question

still remains, have we learned anything? With the amount of effort to

thwart more TMI's and Chernobyl's from occurring, there seems to be the

same amount of effort to change the facts and, quite frankly, not caring

about safe operation of our worldwide nuclear power plants. In

changing the facts and misleading the public, governmental officials and

nuclear plant operators are not doing their part in keeping with public

and environmental safety. Dr. Thomas H. Pigford, professor of nuclear

engineering at UC, Berkely, boldly states, "The president's commission

on the accident (TMI), of which I was a member, concluded that the only

serious health effects were the fright and trauma stemming from technical

errors and from public announcements based on these errors." Despite

claims by the nuclear industry that "no one died at Three Mile Island," a

study by Dr. Ernest J. Sternglass, professor of radiation physics at the

University of Pittsburgh, showed that the accident led to a minimum of

430 infant deaths. (http://www.nitehawk.com/alleycat/nukes,htmljanuary

1980) Another incident in November, 1992, at the Sequoyah

Fuels Corp. uranium processing factory in Gore, Oklahoma, closed after

repeated citations by the government for violations of nuclear safety and

environmental rules. The plant had also been shut down the year before

when unusually high concentrations of uranium were detected in water in a

nearby construction pit. The company, after investigated, had known for

years that uranium was leaking into the ground at levels 35,000 times

higher than federal law allows. The plant's environmental manager, Carol

Couch, was cited by the government for obstructing the investigation and

knowingly giving Federal agents false information. Still today, as

reported in Time Magazine (vol. 147 no. 10), The Nuclear Regulatory

Commission (NRC) released a warning (and shut a one down) to the operators

of 34 nuclear reactors around the country that the instruments used to measure

levels of water in the reactor could give false reading during routine

shutdowns and fail to detect important leaks. Also, at many of these reactors,

the storage of "spent fuel" has exceeded the limits of the pool's capacity.

Should the primary cooling system fail, meltdown could be inevitable.

The problems were first brought to light at Northeast Utilities in

Connecticut by an engineer who had been harassed for raising safety

concerns. The federal government failed to enforce their own laws, and

the NRC would waive safety regulations so that plants could cut costs and

stay on-line. These plants reward employees by not raising safety issues

and harass, reprimand, fire, and even blacklist those employees who do

raise safety issues! With situations like these being uncovered, we are

not learning anything but how to be cheats, manipulative, greedy, and

all-out foolish. Who is on the side of the public (otherwise known as

the endangered) and why are things like this still occurring?

Still, employees and the NRC's "renewed approach" to prevent future

situations show that we have, and still are learning from these

experiences. Also, with the advancement of human factors and

engineering, nuclear plants will continue to be safer to operate. Also,

as countries continue to "grow up" and start working together, the

uniformity of plants being built and employees being trained will only

improve worldwide.

Understanding that accidents will still continue to happen and

differences will abound between professionals interpretations of

problems, there does not look like things will get better. If a

"watchdog" organization can be built to regulate the nuclear industry (as

transportation has the National Transportation Safety Board), and people

(and governments) can set aside greed, personal agendas, and selfishness,

the world would be a better place. As we all know, this is not going to

happen anytime soon, and these types of setbacks will only feed the

probability that other future Chernobyl's and TMI's will occur. It's is

sad enough that the probability is there for a disaster when under the

best conditions possible, but with lenient and unenforced laws (here and

abroad), uncooperativeness between governments, utilities, and engineers,

the chance only increases. If these types of scenarios continue to happen,

we are just waiting for a major worldwide disaster to occur. The future is

in our hands. Our actions will decide what happens!

Roberto Cardenas

rcardena@scf.usc.edu

ISE 370L

1996

____________________________________________________________________

Date: Mon, 8 Apr 1996 02:11:14 -0700 (PDT)

From: ROBIN SETIABUDI IS A CRAZY LOVER OF CHRIST

To: Najmedin Meshkati

Subject: Human Factor Issues in Nuclear Power Plant

MIME-Version: 1.0

HUMAN FACTOR ISSUES IN NUCLEAR POWER PLANTS

Written by : ROBIN SETIABUDI

Class : ISE 370

Date : 8th of April 1996

E-mail : setiabud@scf.usc.edu

Energy consumption has increased in this decade due to the

technological advance. Therefore, better, cheaper and more efficient

ways of fulfilling these demands have to be devised. This led to the birth

of nuclear revolution.

Nuclear energy has proven that electricity could be produced

cheaply and in vast amount. These will led to the growth of an average of

3.3 to 4.2% per year world wide from 1988-2005. In the developing

countries like Middle East and South Asia, the estimated average annual

growth rate of nuclear power production is 19.5-24.2%. And in Latin

America 12.8-16.5%.

According to the International Atomic Energy Agency (IAEA), a

total of 429 nuclear(power) reactors were reported operational and

additional 67 were being built (IAEA Newsbriefs, February/March 1994). In

United States alone, there are 110 operating nuclear power plants

(Najmedin Meshkati, L.A. Herald Examiner, 1989). This showed us the

significant and importance of the role of nuclear energy.

Unfortunately, nuclear energy is without a flaw. April 26, 1989,

the great disaster of Chernobyl, really opened our eyes to the danger of

nuclear energy. Yet another disaster that is closer to our home, the

Three Mile Island (TMI) accident, showed us that anything could happen if

we don't take into consideration the Human Factor into these nuclear plants.

Chernobyl, has entered the chronicle of the 20th century as the

worst technogenic environmental disaster in history (Scientific American,

April 1996). This accident happened during a test (to see how long

the generators would run without power) on one of the reactor, Reactor #4, a

RBMK-1000 design. The operators had disabled the safety systems that

could have averted the reactor's destruction, because the systems might

have interfered with the results of the test. Unfortunately, the

RMBK-1000 has a design flaw that makes its operation at low power

unstable. In this mode of operation, any spurious increase in the

production of steam can boost the rate of energy production in that

reactor. If that extra energy generates still more steam, the result can

be a runaway power surge. By the time this disaster is realized, it is

already to late.

The reactor's core power production surged to 100 times the

normal maximum level and there was a drastic increase in temperature. The

result was two explosions that blew off the 2000 metric-ton metal plate

that sealed the top of the reactor, destroying the building housing it.

The radioactive particles that are carried away by the winds showered

the areas of Ukraine, Belarus, Russia, Georgia, Poland, Sweden, Germany,

Turkey and others. An estimated of 90 million curies (a minimum) of

radioactivity are released. This radiation is hundreds of times more

radiation than was produced by the atomic bombings of Hiroshima and

Nagasaki.

These radiation not only affected the land surrounding Ukraine,

but also the poultry, animals and people that lived in that area. These

people have to be evacuated from this infected area. Many has to undergo

frequent medical check up for their condition. Thyroid cancer rate is rising

among the children. Ukraine 's overall rate of thyroid cancer among

children has increased ten-fold from preaccident levels and now is more

than four cases per million. The psychological damage runs deep in the

mind of the people that are affected. Through fear, Chernobyl still

kills. This unfortunate accident helped to destroy the Soviet Union and

ended the cold war.

The TMI case is not as severe as the Chernobyl, but still as

lethal. Although the accident seriously damaged TMI's core and disabled the

reactor permanently, the amount of radiation that was emitted is

insignificant. Dozens of study that is conducted have been unable to

detect any health effects from it.

This "near Chernobyl" accident is caused by the failure of the

steam valve. The opening of the valve is open, but unfortunately the

display on the control room showed that it is closed. This lead to the

Loss of Coolant Accident (LOCA). LOCA is caused by the loss of coolant

that is surrounding the nuclear core, i. e., as the coolant is lost, the

reactor become overheated and lead to the meltdown of the reactor.

Other factor is that before the accident, there was no systematic

means of sharing information among operators and staff at different

plants, and there was an adversarial relationship between plant

management and the NRC that hindered the sharing of vital information.

Regulators were more concerned with documentation and adherence to

written regulations than with what operating experience should taught

them (L.A. Herald Examiner, 1989).

The role of human factor has so far not been applied to the

control room of the nuclear power plant. The control panels are not

ergonomically designed nor do they conform to the safety standard. Some

of the dial or gauges are way above or below the eye level. Some are to

small to read, and others are covered by the label tags. Some of the

control rooms are of mirror image, and the panels that is on the right

in this room, is on the left for other room. The control boards have no

proper labelings or pointer/separation lines on them, which led the

operators drawing or writing it in by themselves. Some does not have a

video monitor availabe connecting the control room with the nuclear

reactor. There are also no proper training on what to do during a

sequence of emergency situation. The replacement/redesign of the

control board or procedures are simply to expensive and might cost

hundred thousands of dollars.

Some of the facilities do not follow the safety procedures. On

the Wall Street Journal, March 1996, there is an article on the

foreclosure of two plants owned by Northeast Utilities because of

violation of safety procedures. Three times the amount of spent

radioactive fuel rods were being stored in the cooling pool. Other

violation are the screen of the wrong size are used to prevent the debris

from clogging pumps in the cooling system, where water flow is crucial.

Also one of the cooling pumps could not be protected from floods. Rising

temperatures in pools could boil off the water leading to the rod meltdown.

When the people working there tried to point out that they are

having a serious and dangerous working condition, they were sent to the

company psychologist for therapy. Others are being dismissed from their

work due to their being busybodies. The reason that the management does

this is that the replacement or the change of the existing system would

cost them a lot of money in terms of million of dollars, therefore they

choose not to change anything. Any opposition to this would lead to

dismissal or harassment of the workers.

Harnessing nuclear power plants are beneficial for us, but a

proper procedures have to be taken. Dr. Meshkati said in L.A. Herald

Examiner that "The problem is that approaches to ensuring the safety of

large scale technological systems such as a nuclear plant are too

narrowly focused on finding their engineering solution. What is ignored is

how the interactions of human, organizational and managerial factors also

determine and affect the safety of any such system". Other things

includes the proper safety procedures or law and regulations have to be

enforced strictly to ensure the safety of operating the nuclear plants.

There is a need of improvement for the IAEA that IAEA should be given

more discreation and authority in development, adoption and enforcement

of uniform safety standards for the nuclear power plants.

Recommendations for improving the IAEA are twofold: Political and

Philosophical Change( of Paradigm) and Structural Change (Meshkati,

1995). They call for a) to the extent possible, de-coupling safety

related issues from the safeguard programs and other politically-charged

problems; b) a structural re-alignment of the agency to address the

needed organizational dimensions for the implementations of its new

organizational (safety) culture and to enable it to perform its new

global safety roles. It is suggested that Nuclear Safety, which is

presently is one of the four sections under the Department of Nuclear

Energy and Safety, be elevated to the same level as the Safeguards in the

IAEA organizational chart. This newly created "Department of Nuclear

Safety" should report directly to the Director General of the Agency and

its budget should be proportional to and reflect the depth and breath of

its global responsibilities and activities. This new Department of

Nuclear Safety should, at least, be composed of Research, Operation,

Inspection and Compliance divisions.

In conclusion, if human factors are followed, safety regulations

are enforced and foul play are ruled out, the nightmare and tragedy of

Chernobyl and TMI would not and never would happen again. We thus could

enjoy the benefits of nuclear power plants in peace and safety.

________________________________________________________________________

Seth Weintraub

What have we learned from Three Mile Island and Chernobyl and what implications do they have on the state of today's Nuclear Safety?

Nuclear power has become one of the most important energy sources to modern society. Without it, many countries, especially the United States, would suffer a debilitating energy crisis of momentous proportions. There are at least 420 operating nuclear power plants in the World in twenty-six countries. Of those, at least 126 are located in the United States and they account for about twenty percent of the nation's power generated. Nuclear energy is also produced without any of the greenhouse gas by-products that conventional coal and petroleum burning energy facilities generate. Unfortunately though, this great resource comes with even greater potential for environmental danger. Because of the importance of nuclear energy however, the hazards that go along with its production must be seriously addressed.

The environmental dangers of nuclear power must not be underestimated. There have already been two major nuclear power disasters and countless other close calls. The first accident, at Three Mile Island, Pennsylvania occurred in 1979. Unfortunately, the partial meltdown could have been avoided if lessons from an earlier close call at Perry nuclear power plant in Ohio had been forwarded to the crew in Pennsylvania. The Perry crew encountered the same situation (core over-heating) and was able to stop the disaster before full meltdown status. However, because of a series of human factors errors and covered up warning indicators, one of the reactors had a partial meltdown. Although the official report states that minimal amounts of radiation spilled into the environment, many scientists believe that a more significant amount was released that could cause health problems in the surrounding areas. In any case, it was an accident that shouldn't have happened and it definitely should have rang enough alarms all over the World to overhaul the industry.

The strongest evidence that this did not occur was the core meltdown of reactor number four at Chernobyl, Ukraine in what was the old Soviet Union on the early morning of April 26, 1986. The crew there was doing some tests that required turning off the safety systems and at the same time bringing the defective RBMK-1000 reactor to a very unstable low power. These two actions proved to be the ingredients for disaster when the core started to boil. Sensing danger, an operator made the fatal mistake of pressing a button that activated the automatic protection system. However at this time it was too late and within three seconds the core had heated to one hundred times the maximum level. The result was two explosions which blew off the 2,000 metric ton metal plate that sealed the reactor thus releasing two-hundred times the radiation of Hiroshima and Nagasaki combined! In the ten days that followed, the radioactive graphite that was once housed inside the reactor burned, spreading radioactive uranium and plutonium and the even more deadly fission products which include cesium 137, strontium 90, and iodine 131 into the atmosphere. The cloud put high doses of radiation all over Ukraine, Belarus and Eastern Europe. Effects were even felt in the United States and Japan. Over 260,000 square kilometers of land were contaminated, much of which is unsafe to live on and much more that is unsafe to farm. Food supplies as far away as Sicily and England had to be dumped because of contamination. Although official estimates indicate that 100,000 people will die prematurely because of the radiation, some scientists think that the death toll might exceed that of World War Two! Although the fire and release of nuclear waste has been contained, the giant Sarcophagus that houses the disaster that was once known as reactor number four is in danger of collapsing because of the inadequate working conditions in which it had been constructed. Scientists now fear its collapse could be the most ominous nuclear threat in the World.

Obviously then, the possibility for another Nuclear disaster must be eliminated entirely. Every necessary step must be taken. I have outlined some of these steps below:

First of all, all unsafe nuclear power plants MUST be shut down or upgraded to much stricter standards. This includes almost all Soviet built plants and especially the ones with the defective RBMK-1000 (the same as Chernobyl's) reactor at the center. High on the list of dangerous reactors are the two new nuclear power plants going up in Cuba (which is less than 50 miles from the coast of Florida) that are based on old Soviet designs and engineers deem dangerously unsafe. Safety features that need to be included comprise integrating human factors into the control rooms of these power plants. Using the proper ergonomics would drastically decrease the threat of dangerous human errors in a very critical, no mistake environment. Still, upgrading the safety features of nuclear reactors is an extremely costly and time consuming task. However, the consequences of unleashing another Chernobyl on the environment far outweigh the work necessary.

Secondly, a new World Wide organization must be formed to monitor the safety of the operating nuclear power plants. Unlike its predecessors, the International Atomic Energy Agency and the American Nuclear Regulatory Commission, the new organization must be made up of completely neutral parties. No members or affiliates of the nuclear energy sector can be included because their judgment can be easily swayed. The organization must also be able to enforce punishment on any violators that it sees fit. This power must be guaranteed and enforced by the Nuclear Countries. Because money is so often the reason to cut corners on safety, large monetary fines should waged against violators. This would preempt any benefit of operating a dangerous nuclear facility in order to save money.

Lastly, and maybe most important, we must educate the public, especially in those areas highest at risk, on the dangers of nuclear energy. We must be aware of the consequences of another nuclear meltdown like Three Mile Island and Chernobyl. We must learn from the mistakes that were previously made that caused these catastrophes. We must not let worried nuclear engineers be silenced by money-hungry utility companies. We must educate the people of the former Soviet Union on the dangers that await in their back yard. And we absolutely, positively must not forget the innocent people of the area within the radioactive cloud of Chernobyl whose shortened lives and nightmarish suffering should be a warning to us all of the importance of nuclear safety.

Refrences used throughout this article:

"Ten Years of the Chernobyl Era," Yuri M. Shcherbak, Scientific American April 1996 pp 44-49

"Are we safer after Three Mile Island?" Najmedin Meshkati, Los Angeles Herald Examiner, March 28th 1989 pA17

"10 Years Later..." Michael Specter, New York Times, Sunday March 31,1996 pA1

"Blowing the 'Whistle on Nuclear Safety" Time Magazine, March 4, 1996, vol147, no. 10, pp 47-54

________________________________________________________________________

From: Songpol Piyaratpaisal

Subject: What have we learned from TMI 17 years later?

To: meshkati@bcf.usc.edu

Date: Mon, 8 Apr 1996 03:20:51 -0700 (PDT)

Cc: piyaratp@girtab.usc.edu (Songpol Piyaratpaisal)

MIME-Version: 1.0

Did We Learn Any Lesson?

By: Songpol Piyaratpaisal (email: piyaratp@scf.usc.edu)

Every new invention or technology is known to human for having problems

or effect that they can not foresee in the future. For the invention of

nuclear energy, new wors usch as "meltdown" has been introduce into the

vocabulary. A wise man once said, "It is wise for a person to learn from his/

her own mistakes in order for a better and stronger personality." But it seems

that the people did not learn any kind of lesson from the mistake that happened

seventeen years ago at Three Mile Island(TMI) nuclear power plant.

After the TMI incident, people still questioning about the safety of

the nuclear power plant. Cases of minor, major, and similar to the TMI

problems had been occurring after the new regulations provided by The Nuclear

Regulatory Commission(NRC) as a guideline for nuclear power plant to follow.

Even though NRC distributed their regulators in every nuclear power plant

throughout America for a close regulating on the new regulations after the TMI

incident, and little effort has been put on enforcing the new regulations. The

NRC admitted that investigating too much problems(minor and major) which stack

on top of one another can lead to the lost of time to focus on other more

important problems.

NRC organization is badly structure as departments in the organization

did not interact with one another. This is not the worse problem for NRC

organization to enforce the new regulations, instead the worse problem is on

the regulators which suppose to keep an eye on any wrong doing from the nuclear

power plant throughout the nation. Regulators that have been distributed by

NRC knew of several problems existing in a nuclear power plant but pretending

not to know it and did nothing for any safety prevention stated in the new

regulations.

One of the most talk about case is the Northeast Utilities which it is

well known for firing whistle blowers on the safety issues about the Northeast

Utilities' nuclear power plant. It is also well known for cutting down cost

for running their nuclear power plant by reducing the cost for spending on

safety matters. But once NRC did an investigation provided by a whistle

blower, Northeast Utilities decided to down size the work force throughout the

company own nuclear power plant in the nation.

Another most talk about case is the Chornobyl which cause a global

outbreak on the safety and environmental issues. As a footnote in history,

Chornobyl is the worse environmental disaster during the 20th century. The

humanity consequences from the disaster is countless but the official Soviet

number has been very low comparing between this two statistics.

Nevertheless, all of this incidents can not happened if only the

appropriate desgin of the control board is incorporate in maintaining the

safety of the nuclear power plant. In other words, interaction between the

machine and human is very poor. And there is a limitation for human to

withstand the workload and stress for their daily routine job.

In order for companies to take their nuclear power plant open from any

violation they made, companies have hired lawyer to prolong or extent the

lecause the NRC did not take the regulations seriously, often they just skip

the important issues of the report and go on to the next case.

The only good thing that the NRC regulate is the training course which

workers have to go through for training under stress and pressure in case of

emergency similar ot the one in TMI and Chornobyl. It help to build confident

in the workers when encountering in a real situation. The NRC have developed

a department specially for the whistle blower to bring any important attention

on the safetyissues toward the nuclear power plant industries. Improvement in

the design of the control board has become a major concern which human factor

play a major role in the designing.

In conclusion, people make mistake but they do not learn from it. In

other words, history always has a way of repeating itself. The NRC

organization is incompentent in carrying out the role for regulating the

safety of the nuclear power plant industries. And the regulators distributed

by the NRC is not enforcing the regulations guideline which lead to several

incidents similar to TMI. The key is in the NRC, enforcing the regulations

ponce its structure properly withing the organization and industries.

__________________________________________________________________

What have we learned from Three Mile Islands ?

Implication for Future Chernobyl

Susana Wijaya

swijaya@aludra.usc.edu

ISE 370L

1996

On March 28 seventeen years ago, a major nuclear accident has turned the world attention to nuclear industry. Study had been conducted to search for the possible causes of the accident. The result of the study showed that lack of Human Factors implementation plays the major role. For instance, the poor design of the control room, no indicator for the actual position of Pilot-Operated-Relief-Valve(PORV), and poorly trained operators.

Despite the lesson from TMI, at that time, other nuclear power plants still did not see the necessity of the implementation of Human Factor was critical. The more crucial nuclear accident happened seven years later on April 26, 1986 in Chernobyl, Ukraine. Lack of human factors consideration at the design stage is one of the primary causes of the Chernobyl accident(Meshkati, 1991). This accident has made the unknown small town to the symbol of technological disaster. The radioactive fallout was detected all over the world, from Finland to South Africa (Meshkati, 1991). The effect of this accident has spread throughout the world especially neighborhood countries. The poor Belarus, which has no any single nuclear power plant, has to suffer the radioactive contamination. The disaster left one-fourth of Belarus inhabitable (The New York Times, 1996). This forces the people left their home land, and buried their memories and hopes in the contaminated land. Furthermore, the children have to suffer the thyroids cancer which made them depend on injection of thyroids hormone for their lifetime. In spite of the tragic effect on people, two of the Chernobyl reactor are still operating due to the need of power supply.

In these days, ten years after the Chernobyl disaster, most people still do not put attention to the issue of nuclear safety. They overlook that the main reason why nuclear meltdown happens is violations of human factor principles in the nuclear plant safety measures. The violations can take many forms, such as poorly design control room, and discourage employee to report safety measure violation. Why violations happen can be traced to financial problem and Nuclear Regulatory Commission failure in enforcing nuclear plant safety measure.

According to the article, "Blowing the Whistle on Nuclear Safety"(Times, March 4,1996), the main problem is the financial condition of nuclear plants. The financial condition is not limited to the funds for nuclear plant safety control only, but also to funds to cover plant operating cost, wages, equipment cost, and other direct and indirect expenses. In short, the primary problem is budget allocation to cover nuclear plant's expenses. If fund to cover expense is inadequate, nuclear plant management tends to cut the nuclear plant safety funds first to be allocated to cover those expenses.

The question is why plant management chooses to cut the safety funds rather than try to cut other funds? A probable answer is that the plant management feels that safety funds and equipment do not contribute or support to direct plant operating activities. The management notion here the plant is still running anyway even though there is no safety items and funds.

The notion may come from "precondition mind". The management at one time did violate safety standard and remove safety items for sale and the nuclear plant was running without problem. We can see in Millstone plants which do not have state-of-the-art cooling system, keep doing the emergency procedure by performing "full-core offloads" instead of one-third as required (Time, March 4,1996). The violation is repeated and there is "nothing wrong" at the plant, as the result management mind has been precondition to believe that it is all right to ignore safety standard. There are two things should be noted; first, the management knows that they have violated the safety standard(including cut safety funds, ignore safety regulation). The second, "nothing wrong" happens because management does not see the immediate effect of the safety standard violation. As the result, plant management takes safety regulations, funds, and equipment for granted. Management does not have to cut safety fund budget if there is all plant expenses can be financed in full.

Beside financial budget problem and management internal problem as discussed before, there is also another important cause contributes to safety control; Nuclear Regulatory Commission(NRC) ineffectiveness in dealing with nuclear plant safety requirement. Although there is financial dilemma is the primary source of nuclear safety violation, NRC at very least can prevent nuclear plant management to allocate safety budget and sell safety equipment. Unfortunately, there are many cases that NRC is ineffective in handling safety violation. For instance, NRC suggested as much in a 1985 agency directive on "enforcement discretion," which allowed the agency to set aside hundreds of its own safety regulation (Time, March 4,1996).

It is the time that NRC, government, and nuclear plant management collaborate to promote nuclear plant safety measures. Not cutting nuclear plant safety funds is the first step toward improved nuclear plant safety. Furthermore, implementation of Human Factor in nuclear plant design and research in safety are the next steps to increase nuclear plant safety standard. If we do not pay attention to the safety issue, sooner or later future Chernobyls will haunt our world.

References

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

Michael Specter, 10 Years Later, Through Fear, Chernobyl Still Kills in Belarus. The New York Times, March 31,1996.

Blowing the Whistle on Nuclear Safety, Time Magazine, March 4, 1996.

_______________________________________________________________________

Date: Mon, 8 Apr 1996 14:04:01 -0700 (PDT)

From: Miss Tiffany

To: meshkati@mizar.usc.edu

TIFFANY N. LEGINGTON

tnleg@scf.usc.edu

ISE 370L

April 8, 1996

"WHAT HAVE WE LEARNED FROM THE THREE-MILE ISLAND INCIDENT?"

It is difficult to ascertain whether we have really learned a lesson

from the incident at Three-Mile Island which occurred on March 28, 1979.

Although Three-Mile Island did display the importance of increased safety in

nuclear power plants, another similar accident still occurred at Chernobyl

seven years later. So the question remains: "Did the Three-Mile Island

incident really raise consciousness?" Not as much as it should have.

The incident at Three-Mile Island should have been a lesson to prevent

further mishaps at nuclear power plants. Although the accident did not present

any serious problems, such as deaths or severe radioactive pollution, it was an

important warning to the nuclear power industry as to the possible severities

of nuclear power plant mishaps.

One of the problems with mishaps such as the Three-Mile Island incident

is that the government is constantly attempting to hide and cover up issues

which are integral to improving conditions at nuclear power plants. This is

especially evident when one investigates the incident which occurred at the

Davis-Besse Plant in Ohio two years prior to Three-Mile Island. The problem

which occurred at this plant was identical to the problems faced at Three-Mile

Island, however the information was not disseminated publicly. If it had been,

nuclear power plant workers could have studied the problems at Davis-Besse and

would have been able to recognize the signs of a malfunction in the plant at

Three-Mile Island.

I wholeheartedly agree with the statements made by Najmedin Meshkati in

his anaylsis of Three-Mile Island which was published in the Los Angeles Herald

Examiner on March 29: "Thus, to better ensure the safety of a nuclear power

plant, or any large-scale technological system, a holistic approach must be

undertaken, one that not only gives weight to human and technical factors but

also how the two work together." This statement sums up the problems with the

incidents at Davis-Besse, Three-Mile Island, and Chernobyl. If human factors

techniques had been incorporated into procedures at these three plants, these

mishaps could have been avoided.

The Chernobyl nuclear power plant accident on April 26, 1986 was a

haunting reality of the negligent thinking that dismissed the Davis-Besse and

Three-Mile Island incidents. Chernobyl reminded us of the importance and need

for serious attention to be given to the anaysis of safety and training in

nuclear power plants. The series of events which took place at Chernobyl were

similar to Three-Mile Island in that first, there was a special circumstance

relating to the time of the incident. At Three-Mile Island, the incident

occurred at an unpredictable time when there were broken indicators and

equipment, which added to the emergency. At Chernobyl, the incident occurred

while the operators were conducting an experimental test. Ignorance

contributed to both of these incidents. At Three-Mile Island, the operators

were not properly trained to handle an emergency situation and at Chernobyl,

the operators did not know the effect their study would have on the the plant's

system. This leads to the idea that operators of nuclear power plants are not

properly trained in the efficient running of a power plant and definitely not

trained in emergency situations.

Presently, there are many nuclear power plants across the world which

have not been designed using human factors tools. This is the first step in

improving operations at nuclear power plants. In order for employees to

perform at maximum capability, designers need to take into account human needs,

capabilities, and limitations. The second step is to analyze these human

needs, capabilities, and limitations and use this information to properly train

and condition employees as to how to properly run a plant. In the Three-Mile

Island incident, the employees later admitted that they did not understand the

procedural manuals and instructions. This is a problem when there is a mishap

that occurs and employees do not know how to handle the situation. If the

employees were to undergo a series of simulated tests, they would be better

prepared if a mishap were to happen. Also, employees at all three incidents

were not prepared to handle many simultaneous events at once. In the emergency

procedure manuals, there is often instructions for each individual incident,

but does not provide information on how to handle chains of events at these

plants.

The Institute of Nuclear Power Operations was an excellent idea in

helping to prevent future accidents. This group, which is comprised of every

utility in the United States and 13 other countries, can help to enforce

quality standards in management and operations. The database which this

institute has implemented is a wonderful way for plant operators across the

country to exchange information and keep communication open. This can help to

increase operators awareness of what is happening at other plants in order to

prevent unnecessary accidents. This is especially significant considering the

mishap at the Davis-Besse plant. If this database had been in implementation

then, Three-Mile Island would have been avoided. Operators at Davis-Besse

could have alerted operators at Three-Mile Island and thus, they would have

been prepared and knowledgeable about the series of events which took place.

Even after the Davis-Besse, Three-Mile Island, and Chernobyl incidents,

there are still occurances of serious safety problems in nuclear power plants.

An example is the Northeast Utilities' two plants which might be shut down

soon. We still have not learned the importance of raising our consciousness

of the importance of strict adherance to safety codes.

In answer to the question posed initially: "Did the Three-Mile Island

incident really raise consciousness?" I don't think so. It was a mishap which

could have been avoided and thus was relived in the Chernobyl accident, which

was thousands of times worse. Three-Mile Island was a warning to the nuclear

power industry which was not taken seriously. As a result, an estimated 20

million people were affected by radiation and about 300,000 deaths related to

the Chernobyl incident. Fortunately, our government and other governments

across the seas have begun to understand the severity of this issue, and are

taking the necessary steps to avoid nuclear power plant accidents in the

future. It's just a shame that it took an accident like Chernobyl to finally

wake people up.

_______________________________________________________________________

What I've Learned About Nuclear Power

Travis Tucker

tucker@scf.usc.edu

In my sophomore year in high school, we briefly studied the political debate. We broke up into teams of four, and from there we were instructed choose a debatable topic. After some time for research, two of us would debate the other two of the group in the structured debate format on the topic, and the class would decide the winner.

Our topic was nuclear power. The accident at Chernobyl was only four years old at the time, so it was still fresh in every one's minds. I could also find plenty of facts on the disaster to use as focal points to the dangers of nuclear power. I had detailed accounts of projected damages, human and otherwise. I had a "worst case scenario" example of nuclear power plant disaster- complete with horrendously large numbers of lives lost, increases in cancer, polluted environment, etc.

When the debate I thought I had won was finished, I was surprised to find out the rest of the class saw things my opponents' way. I had failed to show my cause in their eyes.

I wish I knew then what I know now. Granted, we've probably learned a lot more about the effects of Chernobyl since I was in high school. Furthermore, I don't believe nuclear reactors are a source of energy that should be completely abandoned. My position during the debate was that we should halt their construction and possibly their use until we were absolutely sure how to keep them safe. This would mean completely understanding the faults that caused Chernobyl's disaster. I did not think we should be blindly running a source of power that of which we could not completely control.

I read all of the articles Dr. Meshkati distributed in class, and I remember most of what I learned about it that time in high school. Of them all, what disturbed me the most was the TIME magazine article. Maybe it was the chronology of the reading I chose. I read my professor's testimony on improving the IAEA's effectiveness, all the articles on the dramatic effects of Chernobyl's radiation, how it's even caused psychological trauma to the citizen's of Belarus, who I see as the prime victims of the disaster.

This was once a Soviet republic that bore the brunt of "the worst technogenic environmental disaster in history". This, despite just sharing a border with the republic that ran the reactor. Now, it stands alone as a country to some how deal with having 25% of it's land uninhabitable- contaminated.

Anyway, after reading all these "testimonies", I read the aforementioned article enlightening me to the various bureaucratic and political horrors that plague my own country's nuclear energy programs. What must be done to reform the status quo of this time bomb waiting to go off?

Are the suits and other professionals running this industry as informed as they should be? Are the regulatory members of the NRC? Have the read of the horrors of Chernobyl- in all of its entirety to this date? I would surely hope it is required to do so. It is clear the working professionals (engineers, or in some cases, "whistle blowers") do. When they exercise their knowledge are rewarded with a lay off or bureaucratic roller coaster ride some will give up on.

Is the public as informed as it should be? I compare them to my classmates in high school. I could sense a blind trust in a system they knew little or nothing about. A "somebody's in charge of keeping it safe" or even more incorrect "if it happens, I won't be anywhere near it". I hope the recent cover article opened many previously shut eyes to the problem we all face. The more the general public is aware of the goings on at these plants, the harder it will be to sweep problems under the rug.

In my eyes, information; knowledge- that's the only way I can see people truly making an effort to control this animal called nuclear energy. With unbiased, hardcore fats, it's hard to see things from any other perspective.

________________________________________________________________________

Date: Mon, 8 Apr 1996 14:09:22 -0700 (PDT)

From: Vasko Rizof

To: Najm Meshkati

Subject: TMI Paper

MIME-Version: 1.0

WHAT HAVE LEARNED FROM THREE MILE ISLAND AND CHERNOBYL ACCIDENTS? For

almost 4 months now, I have been reading, listening, researching and

watching about the nuclear power plants, their operations, advantages and

disadvantages and most importantly their safety impact. When we look at

the Three mile island, Chernobyl, Bhopal which are by far the most tragic

incidents the question still remains: are we safe from another accident or

did we learn something from the these incidents so that we can say we know

how to make the plants much more safer?

Well before I answer that question with my knowledge take a look

at what the authorities, presidents, commissioners, etc. say about it. all

the commercial nuclear reactors operating on Russian theritory are nothing

better than bombs temporarily generating electricity(Alexei Yablokov, LA

Times, 92), dozens of nuclear power stations which could explode at any

moment(Francois Mitterrand, Independent, May 18, 94), worrisome, even with

the safety improvements that have been made since the Chernobyl

accident(US Nuclear Regulatory Commission, GAO, Nov. 91), we can expect a

major nuclear accident to occur roughly every ten years(Nuclear safety of

the IAEA, Greenpeace Magazine, Jan. 91), these pieces were taken from the

Dr. Najmedin Meshkatis testimony for the Critical role of the United

Nations in ensuring the safety of nuclear power plants around the world

and the list keeps going on and on.

As you can see and from my understanding of the matter we are

simply sitting on a time bomb waiting to explode AGAIN. What more will it

take for us as a world to take some kind of action(not words) to make

these nuclear power plants safer?

First it was the Three Mile Island accident that scared the world

to death, but the government and the regulatory commissions and the

experts told the whole world that the accident helped them to find out

their safety problems and they were being fixed and nothing like this

would happen again. Just after 7 years we had Chernobyl which still scares

us to death. The radiation released after the explosion at the reactors

core on April 26, 86 in Chernobyl was nearly 200 times that of the

combined releases from the atomic bombs at Hiroshima and Nagasaki. So who

do we trust? On the night of the accident, if the plant operators were not

conducting a test to see how long the generators on reactor #4 would run

without power, or if they had not disabled the safety systems that could

have averted the reactors destruction because the system might have

interfered with the results of the test conducted, would we be any safer?

Simply no, the accident at that time would have been simply DELAYED. What

did the authorities said again, the same as before, but how much can we

trust them?

Even though there are a lot of speculations on these two accidents

in my point of view there are 2 major problems: 1) Human-Machine

interface, 2) ineffective work of regulatory commissions. To best describe

the first problem take a look at the following statement which appeared in

the conclusion of the IAEAs Summary Report on the Post-Accident Review

Meeting on the Chernobyl Accident (1986): 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. I wish they are valuable for the remaining 429 reactors

of those 58 Soviet-Designed nuclear reactors including 16 Chernobyl type

operating all over the world. It does not like that it was valuable for

these remaining reactors because the western engineers believe that at

least 26 of these reactors should be closed as soon as possible according

to the Economist article Aug. 15, 92. When we look at the second problem

which is ineffective work of regulatory system for the power plants, I

would like you to read the article called blowing the whistle on nuclear

safety, how a showdown at a power plant exposed the federal governments

failure to enforce its own rile. that was published just a month ago on

March 4, 96 in Time magazine. After reading this amazing investigation I

could not help being simply scared of the operations and the actions that

go behind the scenes in the plants and the government regulators actions

to prevent these actions. What would you expect from a plant where the

bonus system is set up to reward employees who do not raise safety issues

that incur costs and those who compromise productivity see their bonuses

reduced. Believe it or not it is happening right here and right now.

Another simple note on this issue is, remember the good old Atomic Energy

Commission (AEC). It was build to promote safe application of nuclear

energy, but look what we have now (NRC) which promotes regulation of

nuclear application, I will leave it up to you to decide where the SAFETY

word is gone.....

I would like to end my paper with another article by Dr. Prof. Najmedin

Meshkati of human factors at the Institute of Safety and Systems

Management, USC. titled are we safer after Three Mile Island? That was

published on LA Herald Examiner March 28, 89. In this article Dr. Meshkati

says to be sure, when accident does occur, human error invariably is cited

as its major cause. But that is somewhat of an oversimplification. But

what is a human error in these accidents? Is it that somebody pushed a

wrong button or an operator perceived an information and take the wrong

action or send a wrong message or etc. It all comes down to Human-Machine

Interface. If these two can not interact with each other, we are more than

likely to prepare ourselves for another tragedy.

VASKO RIZOF

rizof@chaph.usc.edu

*****************

Vanessa Vasconez

vasconez@chaph.usc.edu

ISE 370l

1996

What have we learned from "Three Mile Island" Seventeen Years Later: Implications for Future Chernobyl(s)

Nuclear energy is a growing source of power in today's world. Currently there are about 436 nuclear power plants operating in 26 countries (IAEA, 12/1989), and 96 new reactors are being constructed (IAEA Bulletin, 1/1990). Nuclear energy is viewed as one of the only sources of power which will generate electricity without contributing to the greenhouse effect. It's popularity is also increasing in developing countries because it is seen as a road to economic independence (Meshkati, 1991). The existence of nuclear power plants worldwide poses great concern for the world.

Each power plant contains large amounts of potentially hazardous materials under the control of only a few operators. Since these plants deal with highly dangerous materials, simple human error or system failure may result in a worldwide crisis. This presents a great risk for accidents with serious health, economic, and environmental consequences. In March 28, 1979 this threat became reality with the Three Mile Island incident.

The consequences brought about by the Three Mile Island incident are not entirely known. The cost for clean up alone is estimated at $970 million, far beyond the amount required to initially build the plant. The ramifications of this incident are disturbing because with proper safety considerations this may have been avoided. One of the factors involved in TMI was the lack of communication among government and regulatory agencies, plant manufacturers, and plant managers.

One and a half years prior to TMI, a similar occurrence was experienced in another power plant which was manufactured by the same company as that of Three Mile Island plant. If the previous incident had been properly investigated and findings communicated to the other plants manufactured by the company in question, TMI incident may have been avoided. In addition, one year before this incident the porv at TMI stayed in the open position and caused a LOCA. Instead of learning from this accident, management chose to ignore this incident. The lack of initiative on behalf of plant manufacturers and plant managers to act on occasional warnings and eliminate the potential hazards may lead to a serious catastrophe if this behavior is not eliminated.

The lack of incorporating human factors in control rooms for nuclear power plants is also an element which contributed to the TMI incident. On March, 28, 1979 operators in the middle of an urgent situation inappropriately respond to the crisis resulting in further complications. This is due to an inefficient interface between the operators and control panels, and a inferior training system. It was not until the incident at TMI that human factors became an important tool to bring about safety in nuclear power plants.

The attention of all those involved with nuclear plants focused on incorporating human factors in power plant control rooms. The grouping and sub-grouping of panel elements is encouraged to facilitate the identification of related displays and controls. In emergency situations correctly identifying control actuators and corresponding displays is crucial. The connection between human factors in control rooms and nuclear power plant safety is a profound breakthrough initiated by the incident at TMI.

Unfortunately, lessons were not learned from Three Mile Island. On April 26, 1986, the Chernobyl meltdown demonstrated that nuclear accidents may have global consequences. The factors leading to the meltdown are similar as those of TMI. Managerial and organizational factors such as management error, ineffective training, and lack of human factors consideration at the operating stage inducing operator error contributed to the Chernobyl meltdown. Did it take two nuclear accidents to teach the power industry, power plant manufacturers, and regulatory agencies their lessons on safety?

According to "Warriors" in Time Magazine March 4,1996, a few companies do not encourage their employees to raise safety issues. On the contrary, they seem to deter those who question safety procedures. Those employees who have voiced concerns on power plant safety have been fired, harassed, or sent for psychological testing. It is disturbing to hear that a few power plant companies rather continue with a potential safety hazard which may have global consequences than incur additional expenses to eliminate these safety concerns.

In order to insure safety in nuclear power plants in the future, there is a great need for communication and cooperation among government and regulatory agencies, plant manufacturers, operators, managers, and human factors specialists. There has been steps taken to improve safety in power plants but the work is not done. It is vital for employees to be encouraged to share their views and concerns on safety with upper management. As long as we have companies discouraging feedback from employees, we are far from ensuring the public that power plants are safe and future Chernobyl(s) will not transpire.

References

Kerber, Ross, 1996. Was Therapy Used to Punish Nuclear Workers? The Wall Street Journal, March 20.

Meshkati, N., 1991. Human factors in large-scale technological systems' accidents: Three Mile Island, Bhopal, Chernobyl. Industrial Crisis Quarterly, 5: 133-154.

Pooley, Eric, 1996. Warriors. Time, March 4.

Seminara,J.L. & Smith, D.L., 1983. Remedial human factors engineering-Part I. Applied Ergonomics, December 1993.