The Kemeny Commission Report from the pages of Nuclear News

May 26, 2022, 3:15PMNuclear News

This week’s Throwback Thursday post is again about Three Mile Island—this time looking at the coverage from the pages of the December 1979 issue Nuclear News about the Kemeny Commission. The twelve-person commission, announced by President Carter immediately after the accident in April 1979, was headed by John Kemeny—then president of Dartmouth College—with orders to investigate the causes and any consequences of the accident.

The commission’s report was submitted later that year in October and was titled “The need for change: The legacy of TMI.” In his editorial for the issue (p. 25), then NN editor-in-chief Jon Payne was impressed by the speed at which the commission compiled this report. He said, “The Kemeny Commission faced a severe challenge in pulling together and assessing great quantities of material in a relatively short time. Under the circumstances, it did a creditable job. Although the nuclear industry disagrees with several recommendations of the Kemeny Commission, the industry should demonstrate a positive attitude by taking an active role in bringing about needed changes—including many of those recommended by the Kemeny Commission.”

While the report did provide extensive recommendations, which are published in full below, Payne noted that the commission “states that its findings do not require the conclusion that nuclear energy is ‘inherently too dangerous,’ nor that the United States should ‘move forward aggressively’ with additional plants.” And, to the consternation of the antinuclear lobby, the commission did not call for a moratorium on the licensing of new plants, though that ended up happening since applications for nuclear power plants all but dried up in the U.S. in the years after TMI.

The report that appeared in the December 1979 issue from John Graham, ANS D.C. representative, provides a snapshot of the reactions at the time as well as some insights into the issues that faced the industry for the next 40 years.

The Kemeny Report

(From the December 1979 issue of Nuclear News)

The President’s Commission on the Three Mile Island Accident, or Kemeny Commission, has called for sweeping changes in the way nuclear power is managed and regulated. The final report, titled “The Need for Change: The Legacy of TMI,” released at the end of October, focuses on “people problems”-especially those at the Nuclear Regulatory Commission.

With the exception of the control room, the TMI-2 reactor generally got a clean bill of health. If the automatic safety features had been left alone to perform as they were designed to perform, the commissioners agreed, TMI would have been “limited to a relatively insignificant incident.”

The accident was caused by “operator error,” the commission’s report said. However, the TMI-2 operators were insufficiently trained, and especially so with respect to potential accident conditions. Moreover, the procedures written for them to follow were “very confusing” and capable of leading them to take the “incorrect” actions that were taken during the accident.

The commissioners also stressed that the lessons learned from precursory incidents were never extrapolated into new procedures that could have prevented the TMI accident.

At the man-machine interface, the TMI-2 control room was said to be “lacking in many ways.” Computer expert John Kemeny, chairman of the commission and president of Dartmouth College, would have preferred recommendations for a major redesign effort in all nuclear control rooms. However, the report acknowledged that many of the changes needed for safety precautions can be effected without a large redesign effort or expense.

Apart from the control room, the Nuclear Regulatory Commission-its organization, its performance during the emergency, and its inbred “attitudes”—was tagged as a primary cause of the TMI accident. The NRC, the Kemeny commissioners agreed, is a “headless” agency that must be restructured or reconstituted if future accidents as serious as Three Mite Island are to be prevented.

In the health effects area, the commissioners agreed that the accident caused little, if any, permanent damage to the environment—human or otherwise. The most serious effect was said to be “severe mental stress,” which was “short-1ived.”

The offsite radiation dose attributable to the accident was determined to be so low that any potential health effects will be “minimal,” leading to a projected cancer-death potential of from zero to less than 10.

The population within the general area of TMI will sustain an estimated 325 000 cancer deaths during the latent period of any TMI cancer, and these will have nothing to do with nuclear power, the report says, Therefore, any of these cancer deaths that might be attributable to TMI releases will be undetectable.

The recommendations of the Kemeny Commission are reprinted in their entirety beginning on page 29. These are, of course, only recommendations and not words of law. Their importance, however, cannot be minimized. Most of them-or their derivatives, which are often more severe than their antecedents-are being restated and issued by the NRC as new safety requirements for the construction and operation of nuclear power plants.

The first and most controversial recommendation-that the NRC be abolished and replaced by a single administrator agency within the executive branch-will require legislative approval. The chance that this might come to pass, at least before the 1980 elections, does not appear probable. The NRC abolishment issue—along with all the other Kemeny recommendations—will, however, remain highly politicized.


Moratorium

The major bone of contention over the Kemeny Report deals with the question of placing a moratorium on the nuclear licensing process. Many members of the press, the antinuclear lobby, a few members of Congress, and some of the commissioners themselves were clearly distraught that the Kemeny Report did not call for an outright licensing moratorium until some future date when new safety stamps of approval could be issued.

Many of these same people argued that the report raised safety issues that impact immediately on the operating plants, and consequently that these should be all shut down.

Chairman Kemeny admitted that the commission had labored long and hard over the moratorium issue and that at one time or another, at least eight of the 12 commissioners had voted for some moratorium recommendation. No one such recommendation, however, ever received the required majority of seven votes; therefore, a compromise premise was finally voted out.

The compromise Premise calls for the following to be effective in the transition period, while the NRC is being reconstructed or reorganized:

“Because safety measures to afford better protection for the affected population can be drawn from the high standards for plant safety recommended in this report, the NRC or its successor should, on a case-by-case basis, before issuing a new construction permit or operating license: (a) assess the need to introduce new safety improvements recommended in this report, and in NRC and industry studies; (b) review, considering the recommendations set forth in this report, the competency of the prospective operating licensee to manage the plant and the adequacy of its training program for operating personnel; and (c) condition licensing upon review and approval of the state and local emergency plans.”

Is this a moratorium? At least one commissioner and several politicians (see below) said it was, but the majority of the commissioners, including the Chairman, disagreed.

Chairman Kemeny begged that the moratorium question not become the centerpiece in the public debate over the report. In the early reporting period, however, this request fell on deaf ears.


Externals

The basic report is buttressed by a dozen or more separate documents prepared by task-force study groups or by consultants to the commission.

Several of these backup documents are of particular significance. One, prepared by the legal staff, considers the NRC’s organization and performance, and it documents a picture of bickering, confusion (especially during the emergency), and mismanagement at the regulatory agency.

Another task-force document considers the performance of the press at Three Mile Island and whether the public’s right to information was well served during the accident. Its conclusion is that the Public was poorly served by all the major parties to the accident-Metropolitan Edison, the NRC, and the press’

A primary conclusion was that neither the utility nor the NRC was prepared or able to receive and transmit useful information from the control room to the reporters. The post-accident, public-information situation was described as most often chaotic and generally entangled in technical jargon’

For its part, the press was said to be insufficiently educated in nuclear technology to ask the kind of questions that might have provided proper answers. Consequently, much of the information passed to the public was not very good.

By and large, however, this task force decided, the media reported more “reassuring” than “alarming” news of the accident, and only the New York Post and the New York Daily News were cited for some sensationalism in their handling of the news about the TMI accident.

Several commissioners prepared supplemental views, which were gathered into a separate small document and distributed with the report. For example, six commissioners—Bruce Babbitt, Carolyn Lewis, Paul Marks, Harry McPherson, Russell Peterson, and Theodore Taylor-joined in recommending that “[n]o new limited work authorization permits or construction permits should be issued until such time as the NRC or its successor has adopted siting guidelines” consistent with a unanimous commission recommendation that the NRC be required “to the maximum feasible extent” to site new power plants in locations remote from concentrations of population.

In other statements, Babbitt argued the thesis made popular by Alvin Weinberg (NN, July 1979, p. 29) that all nuclear plants should be managed and operated by an elite corps of nuclear specialists outside the scope of conventional utilities; Peterson called for a review of the Kemeny documents by “some of the highly technically qualified critics of nuclear energy available in our country”; and commissioner Anne Trunk took issue with the report’s conclusions on the press coverage of TMI (see “Window on Washington,” p. 33).

Lewis reserved her “supplemental statement”—and the severest critique of the TMI Proceedings—for a guest editorial in Newsweek (November 12, p. 32), where she blasted high technology in general and nuclear power in particular.

A significant supplemental view came in a 10-Page statement by commissioner Thomas Pigford, professor of nuclear engineering at the University of California-Berkeley. Pigford argued that the bad “attitudes” described in the report, whether at the NRC or in the industry, were pre-TMI attitudes, and he noted the major steps that have been taken in the meantime to correct these faults. His major conclusion, however, was that nothing learned from the investigation “suggests that the nuclear power option should be curtailed or abandoned as a result of the TMI-2 accident.”


White House review

The symbolic “first copy” of the Kemeny Report went to President Carter, who was briefed on October 30 on its contents by Kemeny, McPherson, and others.

The President accepted the document, praised the commission for its diligent effort, and promised to give serious attention to the findings and recommendations.

Since this meeting, the White House has announced an interagency review panel, which has 30 days in which to make its own recommendations. This group consists of: the President’s science adviser Frank Press; energy undersecretary John Deutch; Gus Speth, chairman of the Council on Environmental Quality; James McIntyre, director of the Office of Management and Budget; White House counsel Lloyd Cutler; White House energy Policy coordinator Eliot Cutler; domestic policy adviser Stuart Eizenstat; national security adviser Zbigniew Brzezinski, and John Macy, director of the Federal Emergency Management Agency.


On Capitol Hill

Compared to the cautious atmosphere at the White House, the Congressional response to the Kemeny Report was bombastic. On the day after it had delivered its report to the President, the Commission was summoned to a joint public hearing before the NRC jurisdictional subcommittees-the Senate Environment & Public Works Subcommittee on Nuclear Regulation, and the House Interior & Insular Affairs Subcommittee on Energy and the Environment—by their chairmen Sen. Gary Hart (D., Colo.) and Rep. Morris Udall (D., Ariz.).

This affair was presented live on the Public Television Network.

Several members of the Kemeny Commission had made previous commitments and were unable to attend this hearing, which served primarily as a rostrum for a good deal of antinuclear politicking. During these proceedings, the Kemeny Commission was both praised and castigated. Hart, in his opening statement, took exception to the recommendation that the NRC be abolished, and Udall indicated that his primary interest in the report would be to buttress some of his pet ideas about future legislation he will soon present-but probably not during this session.

Rep. Edward Markey (D., Mass.) was the most hostile to the commission, because of its failure to come forth with an absolute moratorium recommendation, and Rep. Steven Symms (R., Ida.) was the most lauditory for precisely the same reason.

Rep. James Weaver (D., Ore.) called the report a de facto moratorium, and commissioner Taylor agreed with that evaluation. Kemeny and McPherson disagreed.

Lewis insisted that Congress should consider that the commission had voted a moratorium, because more than once a majority of the members present had done so, Moreover, she accused the chairman of changing the voting ground rules at a late hour to prevent a voted moratorium. Kemeny hotly rebuked her for this statement. Sen. Jennings Randolph (D., W. Va.) led Lewis into the trap of supporting coal, after she had confessed to having “nightmares” about nuclear power, and he then stated flatly that coal can do it all with no help from nuclear.

The most scathing attack on nuclear power came from Weaver, who stumped for wood power, and who later argued that loss-of-power at a nuclear plant will lead absolutely and irreversibly to a “meltdown.”

Taylor, who explored the China syndrome thesis over and over during the commission’s own public hearings, added his confirmation to Weaver’s notion with the simplistic observation that his home oil burner fails every time the electricity goes off. On the basis of the hearing, it is difficult to predict when and if the findings and recommendations of the Kemeny Commission will be translated into legislative action on Capitol Hill Meanwhile, the burden of implementing these and other safety recommendations shifts to the Nuclear Regulatory Commission.—John Graham


NRC

Licensing “pause” goes on Accepting the Kemeny Commission’s recommendation that it scrutinize each license application on a case-by-case basis (see above), the Nuclear Regulatory Commission said on November 5 that it will now be at least six months and maybe as long as two years before it will again issue a formal license permit.

Rejecting the word “moratorium” as being too final and as suggesting that nothing is being done at all in licensing, NRC Chairman Joseph Hendrie told a hearing of the House Interstate and Foreign Commerce Subcommittee on Energy and Power that he prefers to say there has been a continuation of the licensing “pause,” which began in August. The pause is still needed, he said, while the NRC readjusts itself to the Kemeny recommendations; awaits similar recommendations from its own investigation (said to be due around the end of the year); makes decisions on rulemaking in progress with state and local officials; and conducts other regulatory business.

During this same hearing, Hendrie admitted that certain safety factors could eventually force the derating or closure of some plants near heavily populated areas. He referred specifically to the Indian Point and Zion stations that are sited near New York City and Chicago, respectively

Meanwhile, as an adjunct to these affairs, the NRC’s executive director for operations, Lee Gossick, resigned. Both Gossick himself and the way the functions of his position are statutorily constituted became part of a heated debate that spilled over from the Kemeny Report into House subcommittee hearings.

When pressed by Rep. Albert Gore (D., Tenn.), who chaired the session in the absence of subcommittee chairman John Dingell (D., Mich.), as to the effect of this additional pause” in licensing, Hendrie said the most immediate effect would be on four or five operating licenses and on a like number of plants close to limited work authorizations or construction permits. After about six months, several more plant schedules will be affected. The severest pinch, Hendrie said, will be on the investment money tied up in these projects.

On the subject of the executive director of operations (EDO) post, Gilinsky broke the issue into the open by saying that this NRC is a “no consensus” commission. This peculiar fact, he said, makes it difficult for the EDO to function, because the EDO normally operates under the umbrella of a consensus. Now, every commissioner is telling the EDO to do different-and opposing-things. Moreover, Gilinsky said, this EDO, meaning Gossick, does not have the personal support of the majority of the commissioners.

Gossick testified that the EDO position had been intentionally emasculated by Congress—when the NRC was formed—with the obvious intent that some very pronuclear individual would not get too much power over the day-to-day business at the Commission.

Later, with the press, Gossick also admitted that working with these particular commissioners, who seldom agree on anything, has not been a rewarding professional experience. All in all, he said, he figured it was time for him to step down.

On the question of whether the NRC should be abolished and replaced by a single-administrator agency, all commissioners made long, personal commentaries. In the end, this was their preference: Hendrie, undecided, but appearing to prefer a commission; Gilinsky, commission; Bradford, commission; John Ahearne, single administrator.


THREE MILE ISLAND

Met Ed hit with record NRC fine, Pa. show-cause

Just as it was about to submit formally a new rate relief request to the Pennsylvania Public Utility Commission on November l, Metropolitan Edison Company received what may have been its biggest shock since the Three Mile Island accident itself. The PPUC ordered Met Ed to show cause why its license to operate as an electrical supplier in Pennsylvania should not be revoked. The utility turned in its request anyway, largely because it believes it has no choice; it involves $55 million in revenue through a 16 percent rate hike, a modification of the 12 percent it had asked for in October (NN, November 1979, p. 38).

The Pennsylvania PUC action capped a series of negative happenings for the utility in the latter part of October. First, the Nuclear Regulatory Commission took a vote on whether to revoke the TMI operating licenses; the tally was 2-2 (Peter Bradford and Victor Gilinsky voting to revoke; John Ahearne and Joseph Hendrie, to uphold; Richard Kennedy not present but known to oppose revocation), which was not enough to carry, since a tie goes against a proposed motion.

Then, on October 25, the NRC’s Office of Inspection and Enforcement proposed the largest fine in the agency’s history: $155 000 against Met Ed for TMl-related items of noncompliance. In all, OIE listed a whopping 134 violations, 16 infractions, and one deficiency over a period from October 1978 through March 1979. It levied in full, the fines would have amounted to $725 000, but the NRC is statutorily limited to impose no more than $25 000 in fines over any 30-day period.

The bulk of the violations-126 of them, each assessed at the $5000 statutory limit-pertained to the 125 days that the plant allegedly operated in violation of a procedure requiring that an electromatic relief isolation valve be closed if the valve discharge line temperature exceeded 130 °F. According to OIE, the temperature had been in the range of 180-200 °F from October 1978 to March 1979, and the valve was found to be open at the start of the accident. The OIE stated that it was not closed until more than two hours into the accident, “allowing a significant loss of [reactor coolant] inventory.” The utility had until November 14 to pay or protest the fine; meanwhile, OIE is continuing to sift its data and said it may propose “further enforcement action, such as additional civil penalties or orders to suspend, modify or revoke the license.”

Soon afterward, the Kemeny Commission report-preceded by several information leaks, both authentic and spurious-was finally released (see story on page 26).

If its state license is revoked, Met Ed might effectively cease to exist, since its service area is entirely in Pennsylvania, and it deals only in electricity. The utility is likely to answer the show-cause order sufficiently to send the matter to a round of hearings. Although Met Ed is becoming very familiar with hearing procedures-with one going on for TMI-I restart, possibly another if the NRC fine is appealed, and several appearances before Congressional committees and the Kemeny Commission-this state-level proceeding might eventually take precedence, if the very existence of the company is indeed on the line. The response to the show-cause was due November 21.

The show-cause action may turn out to be the last straw; even so, the PPUC wants to find out how strong the camel’s back is. The utility’s worsening financial picture, the prospect of another NRC assault on the TMI license, the Kemeny Commission report, and the severity of the NRC fines all contributed to the show-cause, which was concerned with what PPUC chairman W. Wilson Goode called, perhaps prophetically, the “ultimate” question: “whether this company has the ability a reasonable cost. This [the showcause] is a mechanism to answer that.”

• Virtually unnoticed amid all of this was the release of the long-range “lessons learned” report by the NRC. In it, the agency generally arrived at the same findings reached by the Kemeny Commission, attributing much of the cause of the accident to human factors, including operator actions and inactions. The report, numbered NUREG-0585, stated that “the most important lessons learned fall in a general area we have chosen to call operational safety.” The 13 recommendations of the report call for such procedural changes as in-plant personnel drills, upgrading of shift supervisor and senior operator qualifications, and annual control room reviews.

Recommendations of the Kemeny Commission

A. THE NUCLEAR REGULATORY COMMISSION

The Commission found a number of inadequacies in the NRC and, therefore, proposes a restructuring of the agency. Because there is insufficient direction in the present statute, the President and Congress should consider incorporating many of the following measures in statutory form.

Agency Organization and Management

The Commission believes that as presently constituted, the NRC does not possess the organizational and management capabilities necessary for the effective pursuit of safety goals. The Commission recommends:

1. The Nuclear Regulatory Commission should be restructured as a new independent agency in the executive branch.

a. The present five-member commission should be abolished.

b. The new agency should be headed by a single administrator appointed by the President, subject to the advice and consent of the Senate, to serve a substantial term (not coterminous with that of the President) in order to provide an expectation of continuity, but at the pleasure of the President to allow removal when the President deems it necessary The administrator should be a person from outside the present agency.

c. The administrator should have substantial discretionary authority over the internal organization and management of the new agency, and over personnel transfers from the existing NRC. Unlike the present NRC arrangement, the administrator and major staff components should be located in the same building or group of buildings.

d. A major role of the administrator should be assuring that offices within the agency communicate sufficiently so that research, operating experience, and inspection and enforcement affect the overall performance of the agency

2. An oversight committee on nuclear reactor safety should be established. Its purpose would be to examine, on a continuing basis, the performance of the agency and of the nuclear industry in addressing and resolving important public safety issues associated with the construction and operation of nuclear power plants, and in exploring the overall risks of nuclear power.

a. The members of the committee, not to exceed 15 in number, should be appointed by the President and should include: persons conversant with public health, environmental protection, emergency planning, energy technology and policy, nuclear power generation, and nuclear safety; one or more state governors; and members of the general public.

b. The committee, assisted by its own staff, should report to the President and to Congress at least annually.

3. The Advisory Committee on Reactor Safeguards (ACRS) should be retained, in a strengthened role, to continue providing an independent technical check on safety matters. The members of the committee should continue to be part-time appointees; the Commission believes that the independence and high quality of the members might be compromised by making them full -time federal employees. The Commission recommends the following changes:

a. The staff of ACRS should be strengthened to provide increased capacity for independent analysis. Special consideration should be given to improving ACRS ‘ capabilities in the field of public health.

b. The ACRS should not be required to review each license application. When ACRS chooses to review a license application, it should have the statutory right to intervene in hearings as a party. In particular, ACRS should be authorized to raise any safety issue in licensing proceedings, to give reasons and arguments for its views, and to require formal response by the agency to any submission it makes. Any member of ACRS should be authorized to appear and testify in hearings, but should be exempt from subpoena in any proceedings in which he has not previously appeared voluntarily or made an individual written submission.

c. ACRS should have similar rights in rulemaking proceedings. In particular, it should have the power to initiate a rulemaking proceeding before the agency to resolve any generic safety issue it identifies.

The Agency’s Substantive Mandate

The new agency’s primary statutory mission and first operating priority must be the assurance of safety in the generation of nuclear power, including safeguards of nuclear materials from theft, diversion, or loss. Accordingly, the Commission recommends the following:

4. Included in the agency’s general substantive charge should be the requirement to establish and explain safety-cost trade-offs; where additional safety improvements are not clearly outweighed by cost considerations, there should be a presumption in favor of the safety change. Transfers of statutory jurisdiction from the NRC should be preceded by a review to identify and remove any unnecessary responsibilities that are not germane to safety. There should also be emphasis on the relationship of the new agency’s safety activities to related activities of other agencies. (See recommendations E.2 and F.1.b.)

a. The agency should be directed to upgrade its operator and supervisor licensing functions. These should include the accreditation of training institutions from which candidates for a license must graduate. Such institutions should be required to employ qualified instructors, to perform emergency and simulator training, and to include instruction in basic principles of reactor science, reactor safety, and the hazards of radiation. The agency should also set criteria for operator qualifications and background investigations, and strictly test license candidates for the particular power plant they will operate. The agency should periodically review and reaccredit all training programs and relicense individuals on the basis of current information on experience in reactor operations. (See recommendations C.1 and C.2.)

b. The agency should be directed to employ a broader definition of matters relating to safety that considers thoroughly the full range of safety matters, including, but not limited to, those now identified as “safety-related” items, which currently receive special attention.

c. Other safety emphases should include: (i) a systems engineering examination of overall plant design and performance, including interaction among major systems and increased attention to the possibility of multiple failures; (ii) review and approval of control room design; the agency should consider the need for additional instrumentation and for changes in overall design to aid understanding of plant status, particularly for response to emergencies; (see recommendation D.1) and (iii) an increased safety research capacity with a broadly defined scope that includes issues relevant to public health. It is particularly necessary to coordinate research with the regulatory process in an effort to assure the maximum application of scientific knowledge in the nuclear power industry.

5. Responsibility and accountability for safe power plant operations, including the management of a plant during an accident, should be placed on the licensee in all circumstances. It is therefore necessary to assure that licensees are competent to discharge this responsibility. To assure this competency, and in light of our findings regarding Metropolitan Edison, we recommend that the agency establish and enforce higher organizational and management standards for licensees. Particular attention should be given to such matters as the following: integration of decision-making in any organization licensed to construct or operate a plant; kinds of expertise that must be within the organization; financial capability; quality assurance programs; operator and supervisor practices and their periodic reevaluation; plant surveillance and maintenance practices; and requirements for the analysis and reporting of unusual events.

6. In order to provide an added contribution to safety, the agency should be required, to the maximum extent feasible, to locate new power plants in areas remote from concentrations of population. Siting determinations should be based on technical assessments of various classes of accidents that can take place, including those involving releases of low doses of radiation. (See recommendation F.2.)

7. The agency should be directed to include, as part of its licensing requirements, plans for the mitigation of the consequences of accidents, including the cleanup and recovery of the contaminated plant. The agency should be directed to review existing licenses and to set deadlines for accomplishing any necessary modifications. (See recommendations D.2 and D.4.)

8. Because safety measures to afford better protection for the affected population can be drawn from the high standards for plant safety recommended in this report, the NRC or its successor should, on a case-by -case basis, before issuing a new construction permit or operating license:

a. assess the need to introduce new safety improvements recommended in this report, and in NRC and industry studies;

b. review, considering the recommendations set forth in this report, the competency of the prospective operating licensee to manage the plant and the adequacy of its training program for operating personnel; and

c. condition licensing upon review and approval of the state and local emergency plans.

Agency Procedures

The Commission believes that the agency must improve on prior performance in resolving generic and specific safety issues. Generic safety issues are considered in rulemaking proceedings that formulate new standards for categories of plants. Specific safety issues are considered in adjudicative proceedings that determine whether a particular plant should receive a license. Both kinds of safety issues are then dealt with in inspection and enforcement processes. The Commission believes that all of these agency functions need improvement, and accordingly recommends the following measures:

9. The agency’s authorization to make general rules affecting safety should:

a. require the development of a public agenda according to which rules will be formulated;

b. require the agency to set deadlines for resolving generic safety issues;

c. require a periodic and systematic reevaluation of the agency’s existing rules; and

d. define rulemaking procedures designed to create a process that provides a meaningful opportunity for participation by interested persons, that ensures careful consideration and explanation of rules adopted by the agency, and that includes appropriate provision for the application of new rules to existing plants. In particular, the agency should: accompany newly proposed rules with an analysis of the issues they raise and provide an indication of the technical materials that are relevant; provide a sufficient opportunity for interested persons to evaluate and rebut materials relied on by the agency or submitted by others; explain its final rules fully, including responses to principal comments by the public, the ACRS, and other agencies on proposed rules; impose when necessary special interim safeguards for operating plants affected by generic safety rulemaking; and conduct systematic reviews of operating plants to assess the need for retroactive application of new safety requirements.

10. Licensing procedures should foster early and meaningful resolution of safety issues before major financial commitments in construction can occur. In order to ensure that safety receives primary emphasis in licensing, and to eliminate repetitive consideration of some issues in that process, the Commission recommends the following:

a. Duplicative consideration of issues in several stages of one plant’s licensing should, wherever possible, be reduced by allocating particular issues (such as the need for power) to a single stage of the proceedings.

b. Issues that recur in many licensings should be resolved by rulemaking.

c. The agency should be authorized to conduct a combined construction permit and operating license hearing whenever plans can be made sufficiently complete at the construction permit stage.

d. There should be provision for the initial adjudication of license applications and for appeal to a board whose decisions would not be subject to further appeal to the administrator. Both initial adjudicators and appeal boards should have a clear mandate to pursue any safety issue, whether or not it is raised by a party.

e. An Office of Hearing Counsel should be established in the agency. This office would not engage in the informal negotiations between other staff and applicants that typically precede formal hearings on construction permits. Instead, it would participate in the formal hearings as an objective party, seeking to assure that vital safety issues are addressed and resolved. The office should report directly to the administrator and should be empowered to appeal any adverse licensing board determination to the appeal board.

f. Any specific safety issue left open in licensing proceedings should be resolved by a deadline.

11. The agency’s inspection and enforcement functions must receive increased emphasis and improved management, including the following elements:

a. There should be an improved program for the systematic safety evaluation of currently operating plants, in order to assess compliance with current requirements, to assess the need to make new requirements retroactive to older plants, and to identify new safety issues.

b. There should be a program for the systematic assessment of experience in operating reactors, with special emphasis on discovering patterns in abnormal occurrences. An overall quality assurance measurement and reporting system based on this systematic assessment shall be developed to provide: 1) a measure of the overall improvement or decline in safety, and 2) a base for specific programs aimed at curing deficiencies and improving safety. Licensees must receive clear instructions on reporting requirements and clear communications summarizing the lessons of experience at other reactors.

c. The agency should be authorized and directed to assess substantial penalties for licensee failure to report new “safety-related” information or for violations of rules defining practices or conditions already known to be unsafe.

d. The agency should be directed to require its enforcement personnel to perform improved inspection and auditing of licensee com pliance with regulations and to conduct major and unannounced on-site inspections of particular plants.

e. Each operating licensee should be subject periodically to intensive and open review of its performance according to the requirements of its license and applicable regulations.

f. The agency should be directed to adopt criteria for revocation of licenses, sanctions short of revocation such as probationary status, and kinds of safety violations requiring immediate plant shutdown or other operational safeguards.

B. THE UTILITY AND ITS SUPPLIERS

1. To the extent that the industrial institutions we have examined are representative of the nuclear industry, the nuclear industry must dramatically change its attitudes toward safety and regulations. The Commission has recommended that the new regulatory agency prescribe strict standards. At the same time, the Commission recognizes that merely meeting the requirements of a government regulation does not guarantee safety. Therefore, the industry must also set and police its own standards of excellence to ensure the effective management and safe operation of nuclear power plants.

a. The industry should establish a program that specifies appropriate safety standards including those for management, quality assurance, and operating procedures and practices, and that conducts independent evaluations. The recently created Institute of Nuclear Power Operations, or some similar organization, may be an appropriate vehicle for establishing and implementing this program.

b. There must be a systematic gathering, review, and analysis of operating experience at all nuclear power plants coupled with an industry -wide international communications network to facilitate the speedy flow of this information to affected parties. If such experiences indicate the need for modifications in design or operation, such changes should be implemented according to realistic deadlines.

2. Although the Commission considers the responsibility for safety to be with the total organization of the plant, we recommend that each nuclear power plant company have a separate safety group that reports to high- level management. Its assignment would be to evaluate regularly procedures and general plant operations from a safety perspective; to assess quality assurance programs; and to develop continuing safety programs.

3. Integration of management responsibility at all levels must be achieved consistently throughout this industry. Although there may not be a single optimal management structure for nuclear power plant operation, there must be a single accountable organization with the requisite expertise to take responsibility for the integrated management of the design, construction, operation, and emergency response functions, and the organizational entities that carry them out. Without such demonstrated competence, a power plant operating company should not qualify to receive an operating license.

a. These goals may be obtained at the design stage by 1) contracting for a “turn-key “plant in which the vendor or architect-engineer contracts to supply a fully operational plant and supervises all planning, construction, and modification; or 2) assembling expertise capable of integrating the design process. In either case, it is critical that the knowledge and expertise gained during design and construction of the plant be effectively transferred to those responsible for operating the plant.

b. Clearly defined roles and responsibilities for operating procedures and practices must be established to ensure accountability and smooth communication.

c. Since, under our recommendations, accountability for operations during an emergency would rest on the licensee, the licensee must prepare clear procedures defining management roles and respons ibilities in the event of a crisis.

4. It is important to attract highly qualified candidates for the positions of senior operator and operator supervisor. Pay scales should be high enough to attract such candidates.

5. Substantially more attention and care must be devoted to the writing, reviewing, and monitoring of plant procedures.

a. The wording of procedures must be clear and concise.

b. The content of procedures must reflect both engineering thinking and operating practicalities.

c. The format of procedures, particularly those that deal with abnormal conditions and emergencies, must be especially clear, including clear diagnostic instructions for identifying the particular abnormal conditions confronting the operators.

d. Management of both utilities and suppliers must insist on the early diagnosis and resolution of safety questions that arise in plant operations. They must also establish deadlines, impose sanctions for the failure to observe such deadlines, and make certain that the results of the diagnoses and any proposed procedural changes based on them are disseminated to those who need to know them.

6. Utility rate -making agencies should recognize that implementation of new safety measures can be inhibited by delay or failure to include the costs of such measures in the utility rate base. The Commission, therefore, recommends that state rate-making agencies give explicit attention to the safety implications of rate-making when they consider costs based on “safety-related” changes.

C. TRAINING OF OPERATING PERSONNEL

1. The Commission recommends the establishment of agency-accredited training institutions for operators and immediate supervisors of operators. These institutions should have highly qualified instructors, who will maintain high standards, stress understanding of the fundamentals of nuclear power plants and the possible health effects of nuclear power, and who will train operators to respond to emergencies. (See recommendation A.4.a.)

a. These institutions could be national, regional, or specific to individual nuclear steam systems.

b. Reactor operators should be required to graduate from an accredited training institution. Exemption should be made only in cases where there is clear, documentary evidence that the candidate already has the equivalent training.

c. The training institutions should be subject to periodic review and reaccreditation by the restructured NRC.

d. Candidates for the training institute must meet entrance requirements geared to the curriculum.

2. Individual utilities should be responsible for training operators who are graduates of accredited institutions in the specifics of operating a particular plant. These operators should be examined and licensed by the restructured NRC, both at their initial licensing and at the relicensing stage. In order to be licensed, operators must pass every portion of the examination. Supervisors of operators, at a minimum, should have the same training as operators.

3. Training should not end when operators are given their licenses.

a. Comprehensive ongoing training must be given on a regular basis to maintain operators ‘ level of knowledge.

b. Such training must be continuously integrated with operating experience.

c. Emphasis must be placed on diagnosing and controlling complex transients and on the fundamental understanding of reactor safety.

d. Each utility should have ready access to a control room simulator. Operators and supervisors should be required to train regularly on the simulator. The holding of operator licenses should be contingent on performance on the simulator.

4. Research and development should be carried out on improving simulation and simulation systems: a) to establish and sustain a higher level of realism in the training of operators, including dealing with transients; and b) to improve the diagnostics and general knowledge of auclear power plant systems.

D. TECHNICAL ASSESSMENT

1. Equipment should be reviewed from the point of view of providing information to operators to help them prevent accidents and to cope with accidents when they occur. Included might be instruments that can provide proper warning and diagnostic information; for example, the measurement of the full range of temperatures within the reactor vessel under normal and abnormal conditions, and indication of the actual position of valves. Computer technology should be used for the clear display for operators and shift supervisors of key measurements relevant to accident conditions, together with diagnostic warnings of conditions. In the interim, consideration should be given to requiring, at TMI and similar plants, the grouping of these key measurements, including distinct warning signals on a single panel available to a specified operator and the providing of a duplicate panel of these key measurements and warnings in the shift supervisor’s office.

2. Equipment design and maintenance inadequacies noted at TMI should be reviewed from the point of view of mitigating the consequences of accidents. Inadequacies noted in the following should be corrected: iodine filters, the hydrogen recombiner, the vent gas system, containment isolation, reading of water levels in the containment isolation, reading of water levels in the containment area, radiation monitoring in the containment building, and the capability to take and quickly analyze samples of containment atmosphere and water in various places. (See recommendation A.7.)

3. Monitoring instruments and recording equipment should be provided to record continuously all critical plant measurements and conditions.

4. The Commission recommends that continuing in- depth studies should be initiated on the probabilities and consequences (on- site and off-site) of nuclear power plant accidents, including the consequences of meltdown.

a. These studies should include a variety of small -break loss-of-coolant accidents and multiple-failure accidents, with particular attention to human failures.

b. Results of these studies should be used to help plan for recovery and cleanup following a major accident.

c. From these studies may emerge desirable modifications in the design of plants that will help prevent accidents and mitigate their consequences. For example:

(i) Consideration should be given to equipment that would facilitate the controlled safe venting of hydrogen gas from the reactor cooling system.

(ii) Consideration should be given to overall gas-tight enclosure of the let-down / make-up system with the option of returning gases to the containment building.

d. Such studies should be conducted by the industry and other qualified organizations and may be sponsored by the restructured NRC and other federal agencies.

5. A study should be made of the chemical behavior and the extensive retention of radioactive iodine in water, which resulted in the very low release of radioiodine to the atmosphere in the TMI-2 accident. This information should be taken into account in the studies of the consequences of other small-break accidents.

6. Since there are still health hazards associated with the cleanup and disposal process, which is being carried out for the first time in a commercial nuclear power plant, the Commission recommends close monitoring of the cleanup process at TMI and of the transportation and disposal of the large amount of radioactive material. As much data as possible should be preserved and recorded about the conditions within the containment building so that these may be used for future safety analyses.

7. The Commission recommends that as a part of the formal safety assurance program, every accident or every new abnormal event be carefully screened, and where appropriate be rigorously investigated, to assess its implications for the existing system design, computer models of the system, equipment design and quality, operations, operator training, operator training simulators, plant procedures, safety systems, emergency measures, management, and regulatory requirements.

E. WORKER AND PUBLIC HEALTH AND SAFETY

1. The Commission recommends the establishment of expanded and better coordinated health- related radiation effects research. This research should include, but not be limited to:

a. biological effects of low levels of ionizing radiation;

b. acceptable levels of exposure to ionizing radiation for the general population and for workers;

c. development of methods of monitoring and surveillance, including epidemiologic surveillance to monitor and determine the consequences of exposure to radiation of various population groups, including workers;

d. development of approaches to mitigate adverse health effects of exposure to ionizing radiation; and

e. genetic or environmental factors that predispose individuals to increased susceptibility to adverse effects. This effort should be coordinated under the National Institutes of Health with an interagency committee of relevant federal agencies to establish the agenda for research efforts including the commitment of a portion of the research budget to meet the specific needs of the restructured NRC.

2. To ensure the best available review of radiation-related health issues, including reactor siting issues, policy statements or regulations in that area of the restructured NRC should be subject to mandatory review and comment by the Secretary of the Department of Health and Human Services. A time limit for the review should be established to assure such review is performed in an expeditious manner.

3. The Commission recommends, as a state and local responsibility, an increased program for educating health professionals and emergency response personnel in the vicinity of nuclear power plants.

4. Utilities must make sufficient advance preparation for the mitigation of emergencies:

a. Radiation monitors should be available for monitoring of routine operations as well as accident levels.

b. The emergency control center for health -physics operations and the analytical laboratory to be used in emergencies should be located in a well- shielded area supplied with uncontaminated air.

c. There must be a sufficient health-related supply of instruments, respirators, and other necessary equipment for both routine and emergency conditions:

d. There should be an adequate maintenance program for all such health-related equipment.

5. An adequate supply of the radiation protective (thyroid blocking) agent, potassium iodide for human use, should be available regionally for distribution to the general population and workers affected by a radiological emergency..

F. EMERGENCY PLANNING AND RESPONSE

1. Emergency plans must detail clearly and consistently the actions public officials and utilities should take in the event of off-site radiation doses resulting from release of radioactivity. Therefore, the Commission recommends that:

a. Before a utility is granted an operating license for a new nuclear power plant, the state within which that plant is to be sited must have an emergency response plan reviewed and approved by the Federal Emergency Management Agency (FEMA). The agency should assess the criteria and procedures now used for evaluating state and local government plans and for determining their ability to activate the plans. FEMA must assure adequate provision, where necessary, for multi-state planning.

b. The responsibility at the federal level for radiological emergency planning, including planning for coping with radiological releases, should rest with FEMA. In this process, FEMA should consult with other agencies, including the restructured NRC and the appropriate health and environmental agencies. (See recommendation A.4.)

c. The state must effectively coordinate its planning with the utility and with local officials in the area where the plant is to be located.

d. States with plants already operating must upgrade their plans to the requirements to be set by FEMA. Strict deadlines must be established to accomplish this goal.

2. Plans for protecting the public in the event of off- site radiation releases should be based on technical assessment of various classes of accidents that can take place at a given plant.

a. No single plan based on a fixed set of distances and a fixed set of responses can be adequate. Planning should involve the identification of several different kinds of accidents with different possible radiation consequences. For each such scenario, there should be clearly identified criteria for the appropriate responses at various distances, including instructing individuals to stay indoors for a period of time, providing special medication, or ordering an evacuation.

b. Similarly, response plans should be keyed to various possible scenarios and activated when the nature and potential hazard of a given accident has been identified.

c. Plans should exist for protecting the public at radiation levels lower than those currently used in NRC-prescribed plans.

d. All local communities should have funds and technical support adequate for preparing the kinds of plans described above.

3. Research should be expanded on medical means of protecting the public against various levels and types of radiation. This research should include exploration of appropriate medications that can protect against or counteract radiation.

4. If emergency planning and response to a radiation-related emergency is to be effective, the public must be better informed about nuclear power. The Commission recommends a program to educate the public on how nuclear power plants operate, on radiation and its health effects, and on protective actions against radiation. Those who would be affected by such emergency planning must have clear information on actions they would be required to take in an emergency.

5. Commission studies suggest that decision-makers may have over-estimated the human costs, in injury and loss of life, in many mass evacuation situations. The Commission recommends study into the human costs of radiation-related mass evacuation and the extent, if any, to which the risks in radiation-related evacuations differ from other types of evacuations. Such studies should take into account the effects of improving emergency planning, public awareness of such planning, and costs involved in mass evacuations.

6. Plans for providing federal technical support, such as radiological monitoring, ‘ should clearly specify the responsibilities of the various support agencies and the procedures by which those agencies provide assistance.“. Existing plans for the provision of federal assistance, particularly the Interagency Radiological Assistance Plan and the various memoranda of understanding among the agencies, should be reexamined and revised by the appropriate federal authorities in the light of the experience of the TMI accident, to provide for better coordination and more efficient federal support capability.

G. THE PUBLIC’S RIGHT TO INFORMATION

1. Federal and state agencies, as well as the utility, should make adequate preparation for a systematic public information program so that in time of a radiation-related emergency, they can provide timely and accurate information to the news media and the public in a form that is understandable. There should be sufficient division of briefing responsibilities as well as availability of sources to reduce confused and inaccurate information. The Commission therefore recommends:

a. Since the utility must be responsible for the management of the accident, it should also be primarily responsible for providing information on the status of the plant to the news media and to the public; but the restructured NRC should also play a supporting role and be available to provide background information and technical briefings.

b. Since the state government is responsible for decisions concerning protective actions, including evacuations, a designated state agency should be charged with issuing all information on this subject. This agency is also charged with the development of and dissemination of accurate and timely information on off- site radiation doses resulting from releases of radioactivity. This information should be derived from appropriate sources. (See recommendation F.1.) This agency should also set up the machinery to keep local officials fully informed of developments and to coordinate briefings to discuss any federal involvement in evacuation matters.

2. The provision of accurate and timely information places special responsibilities on the official sources of this information. The effort must meet the needs of the news media for information but without compromising the ability of operational personnel to manage the accident. The Commission therefore recommends that:

a. Those who brief the news media must have direct access to informed sources of information.

b. Technical liaison people should be designated to inform the briefers and to serve as a resource for the news media.

COMMISSION RECOMMENDATIONS

C. The primary official news sources should have plans for the prompt establishment of press centers reasonably close to the site. These must be properly equipped, have appropriate visual aids and reference materials, and be staffed with individuals who are knowledgeable in dealing with the news media. These press centers must be operational promptly upon the declaration of a general emergency or its equivalent.

3. The coverage of nuclear emergencies places special respons ibilities on the news media to provide accurate and timely information. The Commission therefore recommends that:

a. All major media outlets (wire services, broadcast networks, news magazines, and metropolitan daily newspapers) hire and train specialists who have more than a passing familiarity with reactors and the language of radiation. All other news media, regardless of their size, located near nuclear power plants should attempt to acquire similar knowledge or make plans to secure it during an emergency.

b. Reporters discipline themselves to place complex information in a context that is understandable to the public and that allows members of the public to make decisions regarding their health and safety.

c. Reporters educate themselves to understand the pitfalls in interpreting answers to “what if “questions. Those covering an accident should have the ability to understand uncertainties expressed by sources of information and probabilities assigned to various possible dangers.

4. State emergency plans should include provision for creation of local broadcast media networks for emergencies that will supply timely and accurate information. Arrangements should be made to make available knowledgeable briefers to go on the air to clear up rumors and explain conditions at the plant. Communications between state officials, the utility, and the network should be prearranged to handle the possibility of an evacuation announcement.

5. The Commission recommends that the public in the vicinity of a nuclear power plant be routinely informed of local radiation measurements that depart appreciably from normal background radiation, whether from normal or abnormal operation of the nuclear power plant, from a radioactivity cleanup operation such as that at TMI-2, or from other sources.


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