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Copyright 1998 Union of Concerned Scientists

All rights reserved.

David Lochbaum is a nuclear safety engineer at the Union of ConcernedScientists.

The Union of Concerned Scientists (UCS) is dedicated to advancing responsiblepublic policies in areas where science and technology play a critical role.Established in 1969, UCS has created a unique alliance between many of thenation’s leading scientists and thousands of committed citizens. This partnershipaddresses the most serious environmental and security threats facing humanity.UCS is currently working to encourage responsible stewardship of the globalenvironment and life-sustaining resources; promote energy technologies that arerenewable, safe, and cost effective; reform transportation policy; curtail weaponsproliferation; and promote sustainable agriculture. An independent nonprofitorganization, UCS conducts technical studies and public education, and seeks toinfluence government policy at the local, state, federal, and international levels.

More information about UCS is available at the UCS site on the World WideWeb, at www.ucsusa.org.

Copies of this report are available from

UCS PublicationsTwo Brattle SquareCambridge, MA 02238-9105

Or call 617-547-5552.

Printed on recycled paper.

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6JG�7%5�0WENGCT�5CHGV[�/QPKVQTKPI�2TQITCO�� The Incident Performance Checklist and Scoring System ....................................................................2

4GUWNVU�HTQO�/QPKVQTKPI�VJG�(QEWU�)TQWR� �� Widespread Quality Assurance Breakdown ..........................................................................................3When Were Problems Identified? ..........................................................................................................3Who Identified the Problems? ...............................................................................................................3What Caused the Problems? ..................................................................................................................3

6JG�)QQF��VJG�$CF��CPF�VJG�7IN[� �� The Good ...............................................................................................................................................4The Bad and Ugly ..................................................................................................................................4

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#RRGPFKZ��+PEKFGPV�2GTHQTOCPEG�CV�+PFKXKFWCN�2NCPVU�KP�VJG�7%5�(QEWU�)TQWR�� Calvert Cliffs Unit 1 Nuclear Power Plant ............................................................................................8Cooper Nuclear Power Plant .................................................................................................................9Indian Point 3 Nuclear Power Plant ....................................................................................................10LaSalle Unit 1 Nuclear Power Plant ....................................................................................................11Millstone Unit 3 Nuclear Power Plant ................................................................................................12Oconee Unit 1 Nuclear Power Plant ....................................................................................................13Oyster Creek Nuclear Power Plant.......................................................................................................14River Bend Nuclear Power Plant .........................................................................................................15Sequoyah Unit 1 Nuclear Power Plant ................................................................................................16Surry Unit 1 Nuclear Power Plant .......................................................................................................17

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Nuclear power plant safety demands constant vigilance.It cannot be taken for granted. Equipment has worn outfaster than expected. Electric utility restructuring hasforced plant owners to cut costs to be competitive.These need not jeopardize safety, but maintaining itrequires careful, unstinting attention.

UCS undertook a study to assess how the nuclearpower industry is handling the pressures of agingequipment and shrinking budgets. For our focus group,we selected 10 plants that represent a cross section ofthe nuclear industry. We monitored information abouthow owners and staff discovered and responded toincidents at those plants. The conclusions of this reportare based on data from November 1996 throughJanuary 1998.

The disturbing trend UCS identified was a seriousbreakdown in quality assurance: the plants’ internalauditors, a key element in the quality assurance pro-grams that federal law requires, found none of the morethan 200 problems reported last year. Plant workersfound some problems, inspectors from the NuclearRegulatory Commission found others, and somebecame obvious when equipment broke. But the inter-nal auditors did not identify a single problem.

A second significant finding was that far too manyof the problems reported at the monitored plantsresulted from workers’ mistakes (35 percent of reportedproblems) or poor procedures (44 percent). The gravityof these findings cannot be overemphasized. Humanerror and faulty procedures were major factors in boththe Three Mile Island and the Chernobyl disasters.

In addition to revealing safety concerns afflictingthe nuclear industry as a whole, our monitoring efforts

also identified safety issues at individual plants. At theLaSalle, Millstone, and Sequoyah plants, problemsoften remained undetected or uncorrected over a longperiod of time. Such “hidden” problems seriously erodesafety principles based on redundancy. If, for example,an emergency pump breaks, its backup will be of littleuse if that too has been broken for months.

Not all our findings were bleak, however. Ourmonitoring program turned up good performance aswell as bad. For example, most of the incidents at threeof the plants—Surry, Oyster Creek, and Oconee—wereminor. They were discovered quickly and fixedproperly. These results suggest a healthy regard for theimportance of safety at all levels.

Based on these monitoring results, UCS recom-mends the following:

• Internal auditors need better training or incen-tives to identify problems.

• Workers need additional training or greateroversight to reduce the number of their errors.

• Procedures need revision to eliminate mistakesprompted by faulty guidelines.

• The Nuclear Regulatory Commission needs toimprove its enforcement of federal safetyregulations in order to eliminate instances ofsustained substandard operation.

• The US Congress should formally review theNRC’s regulatory effectiveness to make surethat public health and safety are adequatelyprotected.

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Operational safety is of vital importance at all 104 ofthe nuclear power plants operating in the United States.According to a 1982 congressional report, an accidentat a nuclear plant could kill several thousand people,injure several hundred thousand others, and cost bil-lions of dollars. Thus, safety must be a key con-sideration for the nuclear power industry.

Safety is not a matter of single incidents. No oneerror can cause the meltdown of a reactor. Becausenuclear power plants are complex systems that includemultiple redundancies, many things must go wrong fora major accident to occur. But these safety marginsmust be maintained in order to provide real security:inspectors and tests must identify faulty equipment, andaccurate procedures must guide workers so that they donot make errors. Unfortunately, safety margins arecontinually challenged. Equipment can wear out morerapidly than expected, and pressure to cut costs canresult in poor safety monitoring or slow response toknown problems.

The Nuclear Regulatory Commission (NRC) isresponsible for monitoring performance and enforcingsafety regulations at nuclear power plants. The NRCissues a report card indicating its assess-ment of each plant’s performance everytwo years and a “Watch List” of troubledplants twice each year. But many observ-ers (most recently the US GeneralAccounting Office) have criticized theNRC’s assessment program for failing todetect declining performance in a timelymanner. The Institute for Nuclear PowerOperations (INPO), a peer group that theindustry established after the Three MileIsland accident, assesses plant safety, butits reports are not available for public

review. A third body—Public Citizen—also trackssafety at nuclear power plants. In its periodic NuclearLemons reports, this environmental group lists the25 worst-performing plants, based on economic andsafety indicator criteria.

The Union of Concerned Scientists (UCS) decidedthat we could not rely on the NRC’s assessment pro-gram. We cannot review INPO’s reports. And PublicCitizen offers limited insight into safety practices atplants not on its list of “lemons.” We developed ourown monitoring program to obtain a broader under-standing of safety issues across the nuclear powerindustry. UCS is less interested in the number ofincidents at any particular plant than in how effectivelyplant owners identify and respond to safety problems.Assessing such performance is key to determining whe-ther safety margins are being maintained or eroded asnuclear power plants age and come under pressure tocompete with other technologies.

6JG�7%5�0WENGCT�5CHGV[/QPKVQTKPI�2TQITCOUCS monitors safety margins at 10 nuclear plants. To

be certain that our focus group repre-sents the industry as a whole, we choseone plant from each of the nine catego-ries of reactor type and containmentdesign. In addition, we sought diversityin geographic location, utility size, util-ity structure (private company or publicagency), and site configuration (single ormultiple reactors). We also selectedplants that would allow us to monitornuclear plant license renewal. Finally,we picked two plants from the largest ofthe nine classes so that each of our

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10 focus group members represents roughly the samenumber of operating plants.

This representative monitoring approach allows usto determine whether a problem, either in its discoveryor in staff response, at a focus group plant might affecta larger population—perhaps all the plants in the sameclass, all the plants operated by the same owner, or evenall operating plants. At the same time, we are able toassess whether problems identified at plants outside ourfocus group also exist at any of the monitored plants.Such cases indicate a more widespread problem.

To examine safety margins at plants in our focusgroup, we review publicly available documents, includ-ing the NRC reports on the plants and information fromthe plants’ owners. We supplement these reviews withconversations with plant workers, industry consultants,the NRC inspectors resident at the plants, regional andheadquarters NRC staff, and citizens living near theplants. In evaluating the information that the ownersand NRC officials report about each plant, we useobjective performance criteria based on federal regula-tions.

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5EQTKPI 5[UVGO� Nuclear plants contain thousands ofpumps, valves, motors, switches, and other components.Plant workers perform thousands of tasks. Each year,equipment breaks, testing reveals deficiencies, andworkers make mistakes. These problems are docu-mented in owner and NRC reports.Occasionally, the reports describesuccessful efforts to improve safetymargins. UCS’s evaluation programdoes not simply tabulate the report-ed problems and successes. Instead,we try to determine what thesereports indicate about the perform-ance of plant workers in response tothe reported incidents. To do so, weask questions about each incidentand rely on the reports to providethe answers.

Federal safety regulations form the criteria forscoring the answers. When the plant owner’s responsesatisfies the regulations, the score for an answer is zero.When the owner’s actions exceed minimum standards,

the score is positive. Thus, positive scores reflect com-mendable actions, such as going beyond correcting asingle problem to seek out and correct related problems.When actions do not meet federal regulations, the scoreis negative.

Consider the second question: How is a problemidentified? If the owner finds a problem by efforts thatare not required, then we score it +10. If routinemethods identify the problem, we award zero points. Ifan NRC inspector finds it, it receives a –10 score.Answers to most of the other questions are scored in thesame way. All answers can earn negative points, butonly answers to questions 2 and 9 can earn positivepoints. Since a problem can have more than one cause,question 4 can have several answers, each of whichreceives a score.

The total score for performance during an incidentis the sum of the scores for the answers to the ques-tions, multiplied by a weighting factor (ranging from 1to 2), based on the importance of the equipment affect-ed by the problem. Thus the total score for an incidentcan range from +40 to –260.

Note that the scores, while they reflect the severityof the incident, are not an assessment of its severity.Rather, the scores reflect our assessment of the per-formance of plant personnel in finding problems andresponding to them. Performance involving an incidentwith potentially serious consequences may receive a

positive score if, for example, plantpersonnel identified and dealt withthe problem quickly, thoroughly,and efficiently, then went on tocheck other points where similarproblems might occur. Similarly,performance involving a minorproblem might receive a relativelylarge negative score if plant per-sonnel failed to recognize theproblem over several opportunitiesand, when they did recognize it,failed to correct it. Proper and

timely response to problems is the key factor in main-taining safety margins.

More incidents will receive negative performancescores than positive scores, because difficulties must be

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reported, while successes may not be. Thus, our reviewdoes not capture all the success stories. In addition,there may be few zero scores, since tests and operatoractions that satisfy all requirements often go unre-ported. Since we apply the scoring system equally to allincidents, however, we are able to determine therelative performance of a plant against other membersof our focus group. The plants that aggressively seekout and fix problems will have higher scores than thoseplants that sit back and wait until problems becomeself-evident.

We minimize the subjectivity in our checklist bynot second-guessing the facts that plant owners andNRC inspectors report. For example, if they say an inci-dent’s cause was equipment failure, we score theincident on that basis. We do not presume that theequipment failed because of poor maintenance prac-tices. We also minimize subjectivity by applying con-sistent criteria based on federal regulations to determinesuch things as whether the correction to a problem waseffective. By using consistent criteria, our results pro-vide a meaningful measure of relative performance.

4GUWNVU�HTQO�/QPKVQTKPIVJG�(QEWU�)TQWRThis report covers safety issues during the period fromNovember 1996 to January 1998. For each plant in thefocus group, we reviewed about 50 owner and 25 NRCreports. The results for individual plants are in theappendix to this report.

9KFGURTGCF 3WCNKV[ #UUWTCPEG $TGCMFQYP� Themost serious finding of our monitoring program throwsthe safety of the entire nuclear power industry intoquestion. None of the internal auditors at any of thefocus group plants identified a single one of the morethan 200 incidents reported last year. These auditors arekey elements in the plants’ quality assurance pro-grams—programs mandated by federal regulations.Their entire purpose is to detect problems. The resultssuggest that their focus is misdirected: they are findingminor problems instead of serious safety issues. Thiswidespread breakdown in quality assurance clearlyreflects a lack of industry and NRC emphasis on thisessential monitoring function.

9JGP 9GTG 2TQDNGOU +FGPVKHKGF! A number ofproblems at a variety of plants went undiscovered untilseveral incidents indicating the same problem hadoccurred. This underscores the gravity of the break-down in quality assurance. Overall, only 58 percent ofthe problems were discovered at the first opportunity,24 percent at the second opportunity, and 18 percentwithin a few episodes. If quality assurance at the plantswere effective, more problems would be detected andcorrected sooner.

9JQ +FGPVKHKGF VJG 2TQDNGOU! Federal regula-tions mandate that plant owners inspect and test to findsafety problems. In theory, the NRC inspectors shouldnot find any problems—a plant’s owners should findthem all. In practice, the NRC inspectors identified16 percent of the problems at the focus group plants.Plant workers detected 15 percent of the problems dur-ing testing activities, roughly the same number as theNRC found. Although each plant undergoes thousandsof tests each year, the testing seems surprisingly inef-fective at locating the problems.

9JCV %CWUGF VJG 2TQDNGOU! Five causes1 wereresponsible for the problems at the focus group plants:poor procedures (44 percent), worker mistakes (35 per-cent), equipment failures (29 percent), design errors(22 percent), and maintenance problems (9 percent).Since these plants are all at least 10 years old and pastthe “break-in” phase of operation, procedure revisionsand training programs should have reduced the first twoproblem causes. Poor procedures and worker mistakesare the easiest errors to prevent, yet they persist.

Maintenance activities produced only 9 percent ofthe problems. This relatively low number probablyreflects recent NRC emphasis in this area, culminatingin the adoption in July 1996 of the Maintenance Rule,which requires plant owners to set goals for equipmentreliability. Plant owners have devoted considerableresources to improving maintenance practices, clearlyto good effect. This suggests that regulatory attentionthat prompts comprehensive industry reaction can suc-cessfully reduce problems.

1 Total exceeds 100 percent because a problem can have morethan one cause.


6JG�)QQF��VJG�$CF��CPF�VJG�7IN[Incident performance earning the highest and the lowestscores from our evaluation system illustrates the dif-ference between safe operating practices and riskybusiness. The high scores demonstrate that safe per-formance levels can be achieved, and the low scoresshow that some plant owners were unable, or unwilling,to do what it takes to meet minimum safety standards.And the NRC merely “watched.”

6JG )QQF� Under the UCS rating system, a posi-tive score indicates that the actions taken during anincident exceeded the minimum performance standardsset out in the federal safety regulations. Of the morethan 200 problems reported for the focus group plants,performance during just 15 of them received positivescores. Performance at the five incidents summarizedbelow received the highest scores. These incidentsreflect a healthy—and necessary—attitude towardnuclear safety. These thorough responses not onlyresolved the problems completely, but also effectivelyeliminated the likelihood of future problems.

- Proactive Inspections at Oyster Creek: In1997, staff at Oyster Creek inspected theplant’s emergency cooling system after theowners of the Nine Mile Point Unit 1 facility,which is similar in design to the Oyster Creekplant, reported problems with its cooling sys-tem. Although the problems had not surfaced atOyster Creek and the NRC had not required anyinspections, the plant’s owners proactivelyinitiated a search and were prepared to correctdeficiencies if any existed. No problems werefound. Score: +25

- Training Video at Surry: The training group atSurry developed a video during 1997 thatdescribes reactor control problems experiencedat other plants. The video covers the proceduresand design features that prevent those problemsfrom occurring at Surry. This was a creativeand effective method of conveying lessonslearned at other plants to Surry’s operators.

Score: +25

- Containment Integrity at Surry: During aninspection at the time of a 1997 refueling shut-down, Surry’s managers identified a small holein the containment building that wasn’t prop-erly covered. Even though the problem wasminor, they stopped all refueling work untilstaff had corrected it and had completed asearch for similar problems. No other problemswere found. Score: +20

- Component Defect Warning at River Bend:After finding numerous defects in a 1997 ship-ment of components, the owner of the RiverBend plant contacted the parts manufacturer.The manufacturer determined that an entirebatch of parts had been faulty. When the plantstaff learned that another nuclear power planthad also received components from this batch,the system engineer at River Bend called andwarned his counterpart at that plant.Score: +20

- Thorough Repair at Cooper: During a 1997test, a valve did not operate properly. Initially,Cooper’s owners determined that the valve’sfailure did not need to be reported to the NRCbecause the failed condition satisfied theplant’s operating license. Later, plant workersdetermined that this section of the operatinglicense contained an error dating from changesto the license in the early 1980s. The probingassessment that went beyond the convenientanswer and uncovered the truth offset the factthat the mistake had remained undetected forover a decade. Score: +18.8

6JG $CF CPF VJG 7IN[� Performance that receivesa negative score under our rating system indicates thatactions taken in response to an incident failed to meetthe minimum performance standards set out in the fed-eral safety regulations. Unfortunately, performanceresponding to most of the more than 200 incidentsreported at the focus group plants received negativescores. In five cases, incident performance receivedscores equal to or lower than -100. These five all


involved repetitive problems with safety equipment thathad been tolerated and left uncorrected for years—inone case, for decades. This lack of action raises seriousquestions about how all the inspections and testingconducted by plant workers and NRC inspectors overso many years could fail to identify these safetyproblems.

/ Bad Switches at LaSalle: In late 1996, a flawedcontrol switch caused one of the two pumps thatcirculate cooling water through the reactor to mal-function. Since then, nearly 1,150 other switches,affecting virtually every emergency system in theplant, have had to be replaced because they couldalso be faulty. In 1979, General Electric notifiedLaSalle’s owners that more than 100 suspect con-trol switches needed replacement, but the warningwas ignored. One of the switches GE identifiedactually caused a safety problem in 1990, but onlythat single switch was replaced. The switch prob-lems surfaced again during 1995, but the switcheswere still not replaced. Thus, LaSalle’s ownersignored repeated warnings of widespread equip-ment deficiencies affecting several safety systemsthroughout a 17-year period. Score: -130

/ Old Circuit Breakers at Cooper: In 1997, NRCinspectors discovered that the owners of the Coopernuclear power plant were not performing mainte-nance on the circuit breakers controlling power toemergency equipment every five years as specifiedby the manufacturer. A breaker failure in 1987 hadprompted the plant’s owners to begin a mainte-nance program, but this effort ended in 1994 with25 percent of the breakers unexamined. The poten-tially degraded breakers included those that mustclose in order for the emergency diesel generatorsto supply power to safety equipment and others thatmust close in order for the emergency pumps thatcool the core to start. These breakers had not beenoverhauled since their installation 23 years earlier.

Score: -110

/ “Missed” Safety Valves at LaSalle: In 1997, NRCinspectors discovered that actions taken in responseto a 1992 NRC fire safety warning at the LaSalle

nuclear power plant had not corrected the problem.A fire in the control room could have disabled15 safety valves. LaSalle’s owner had initiallyinformed the NRC that a fire would not affect thevalves. After the NRC raised the concern again in1997, the plant’s owner modified the valves toprotect them from a fire. Score: -110

/ Unreviewed Work Backlog at LaSalle: In 1997,NRC inspectors discovered that LaSalle’s ownershad not reviewed many of the plant’s backlog of1,380 work requests, which covered every emer-gency system, to determine whether the affectedequipment might be broken. Plant workers filework requests when inspections and testing indicatepossible equipment problems. Some requests weretwo and three years old, indicating that the planthad been operating during those years with safetyequipment that may have been broken.Score: -100

/ Recurring Drain Problem at Sequoyah: During arefueling shutdown in early 1997, operators of theSequoyah nuclear power plant drained the pipingconnected to the reactor vessel. The system thatmonitors the level of water in the reactor vessel wasnot used. During the draining, two separate, low-level alarms sounded, but went unheeded. Thewater level was mistakenly lowered below the topof the reactor head, a dangerous situation because itcould disrupt the cooling for the reactor core. Thissame thing had happened twice at Sequoyah during1993, but the procedure changes and other correc-tive actions from those events had not yet beencompleted by 1997, when operators repeated themistake. Score: -100

6JG�7RUJQVThese incidents were near misses. Safety equipmentintended to protect the public during an accident broke,and procedures proved inadequate. The significance ofthese near misses must not be discounted simplybecause an accident did not occur. Safety margins mustbe maintained at every nuclear power plant at all timesto assure that backup is available and functioning whenneeded.


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⇒ Plant owners need to examine their staff andprocedures to determine whether the problemswe identified across all monitored plants arealso problems at their plants. They should con-sider whether they need to

• provide better training or incentives toassure that internal auditors identify prob-lems.

• provide their workers with additionaltraining or greater oversight to reduce theincidence of human error.

• revise procedures to eliminate mistakesprompted by faulty guidelines.

⇒ The NRC should rigorously and consistentlyenforce federal regulations that require nuclearplant owners to implement effective qualityassurance programs and minimize the numberof problems caused by poor procedures andplant staff errors. When a plant is unable orunwilling to comply, the NRC must step in andstop unsafe operation. Because of the greatdanger to the public and the environment, sub-standard performance cannot be tolerated at anynuclear plant.

⇒ The US Congress should formally review theNRC’s regulatory effectiveness to make surethat public health and safety are adequatelyprotected. This congressional inquiry shouldhappen now. It should not be deferred untilafter the next major reactor accident.

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Although the UCS monitoring program does not focuson individual plant performance, we are able to makecomparisons between performance at the plants in ourfocus group and the average across that group. In exam-ining each plant, we focus primarily on the incidentswhere performance received the highest (best) and low-est (worst) scores. These establish a plant’s perform-ance range, indicating strengths and weaknesses andsuggesting what the owners are consistently doing rightand wrong. While we also average the scores for aplant’s incidents, this number is of less value becausemany instances of good or routinely accurate perform-ance will not appear in the reports. However, the aver-age does indicate the plant’s performance relative toother plants in the focus group.

The following chart graphs the data we obtained byscoring incident performance at the focus group plants.Each line shows the range of scores at a plant. The topof the line marks the highest score given to performancein response to an incident at the plant, the bottom of theline marks the lowest incident performance score, andthe dot marks the average for performance across allincidents at the plant. Millstone Unit 3 does not appearon the chart, since it remained shut down during theentire report period. The line furthest to the right showsthe highest and lowest incident performance scores forthe entire focus group, as well as the averageperformance across all incidents in the group.

The following pages discuss the results for each ofthe focus group plants individually.

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The Baltimore Gas & Electric Company operatesCalvert Cliffs Unit 1, as well as the neighboring plant,Unit 2. This nuclear power plant, which is 40 milessouth of Annapolis, Maryland, has a generating capac-ity of 835 megawatts. Unit 1 is a pressurized waterreactor supplied by Combustion Engineering. It is thefirst nuclear plant to apply for a 20-year extension to its40-year operating license.

Operating License Issued: July 31, 1974License Expiration Date: July 31, 2014

/QPKVQTKPI�4GUWNVUCalvert Cliffs’ average incident performance score wasslightly below the average for the focus group. At Cal-vert Cliffs, testing was less effective in identifyingproblems than it was at other plants. Testing activitiesrevealed only 5 percent of the problems at the plant,

whereas on the average such activities located 15 per-cent of the problems.

One incident at the plant was particularly troublingbecause it indicated an improper approach to safetyregulations. To perform maintenance while the plantwas running, workers blocked open a watertight doorthat prevents a flood from spreading to affect equip-ment in other areas. The plant’s operating licenseallows this door to be open for only 24 hours. If it isopen for longer, the plant must be shut down. Workerstwice closed the door briefly—to reset the length oftime the door had been open—then reopened it tocontinue work. The NRC found that the door wasclosed for only 6 minutes in a 49-hour period. Thisaction shows a blatant disregard for safety require-ments.

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The Nebraska Public Power District operates theCooper nuclear power station. The plant, located23 miles south of Nebraska City, Nebraska, has a gen-erating capacity of 764 megawatts. Cooper is a boilingwater reactor with a Mark 1 containment supplied byGeneral Electric. The Nebraska Public Power District, astate agency, does not operate any other nuclear plants.

Operating License Issued: January 18, 1974License Expiration Date: January 18, 2014

/QPKVQTKPI�4GUWNVUCooper’s average incident performance score wasslightly below the focus group average. The plant’sweakest area was in identifying problems. Degradedconditions at Cooper were found at the first or secondopportunity 73 percent of the time, compared with thefocus group’s average of 82 percent. Because problemswere not found promptly, they could not be resolvedpromptly.

Cooper received one of the best and one of the worstincident performance scores within the focus group.This apparent contradiction reflects the plant’s status.The plant demonstrated declining performance during1995 and 1996 and the owners initiated improvementefforts. The high score resulted from a thorough eval-uation of a benign condition that revealed a moreserious problem. The low score resulted when theNRC uncovered a breakdown in emergency equipmentmaintenance.

One incident prompted UCS to notify the NRC.Equipment used to examine spent fuel in the poolwhere it is stored had the wrong settings. As a result,the spent fuel could come closer to the surface of thepool than is safe and than regulations allow. Coopercorrected the settings, but didn’t realize that the prob-lem might have caused workers to receive higher radia-tion exposures. The NRC found that, because of theincorrect settings, workers might have received threetimes more radiation than expected.


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The Power Authority of the State of New York operatesIndian Point Unit 3. The plant, which is 24 miles northof New York City, has a generating capacity of965 megawatts. Indian Point 3 is a four-loop pressur-ized water reactor supplied by Westinghouse. ThePower Authority, a state agency, also operates one othernuclear power plant.

Operating License Issued : April 5, 1976License Expiration Date: December 15, 2015

/QPKVQTKPI�4GUWNVUIndian Point 3’s average incident performance scorewas slightly above the focus group’s average. Begin-ning in early 1993, it had been shut down for three

years while the owners corrected longstanding equip-ment, procedure, and training deficiencies. The plant’sperformance last year indicates that considerable im-provements have been made.

Performance at one incident, however, suggests thatmore work remains to be done. During a shutdown lastyear, workers tested an important cooling-water system.The test data showed that some of the throttle valves inthe system needed adjustment to achieve optimumcooling. The NRC found that many of the throttlevalves were not in the positions specified in theapproved procedures. It turned out that operators hadstarted the plant using a draft procedure that had notbeen reviewed or approved. The rush to start operationshad been placed ahead of safety.

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The Commonwealth Edison Company operates LaSalleUnit 1. The plant, which is 11 miles southeast ofOttawa, Illinois, has a generating capacity of1,036 megawatts. Unit 1 is a boiling water reactor witha Mark 2 containment supplied by General Electric.Commonwealth Edison also operates a second unit atLaSalle, as well as eight other plants.

Operating License Issued: August 13, 1982License Expiration Date: May 17, 2022

/QPKVQTKPI�4GUWNVULaSalle Unit 1 was shut down during the entire moni-toring period. Commonwealth Edison shut down bothunits at LaSalle in September 1996 in order to resolve alarge volume of problems involving equipment andprocedures that were not functioning as intended. Therestart of the units, initially expected in 1997, has beendeferred while the owner struggles with problems atseveral of its plants.

Although the plant remained shut down during theentire monitoring period, there were plenty of incidentsfor UCS to evaluate as the plant’s owners and NRCinspectors probed the depths of the problems. As itshistory suggests, Unit 1 performed significantly belowaverage focus group levels. In fact, it turned in theworst average incident performance score of any focusgroup plant. Design errors caused 42 percent of theproblems at LaSalle 1, compared with 22 percent forthe focus group as a whole. Problems of this type arealarming because they usually indicate that unsafe con-ditions have existed at the plant since its constructionand have remained undetected for the entire period ofoperation, in this case for 15 years.

Longstanding unsafe conditions were also reflectedby the fact that LaSalle required more opportunities toidentify problems. On average, the focus group identi-fied problems at the first or second opportunity 82 per-cent of the time. At LaSalle, that rate was only 72 per-cent. No plant owner can promptly fix a problem itdelays finding.


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The Northeast Nuclear Energy Company operatesMillstone Unit 3. Located 3 miles from New London,Connecticut, this plant has a generating capacity of1,137 megawatts. Unit 3 is a four-loop pressurizedwater reactor supplied by Westinghouse. NortheastNuclear Energy operates three other nuclear powerplants, two of them the other units at Millstone.

Operating License Issued: January 31, 1986License Expiration Date: November 25, 2025

/QPKVQTKPI�4GUWNVUAll three Millstone units have been shut down sinceMarch 1996, when the plant was featured on the coverof Time.2 The owner shut the plants down in order toresolve extensive problems involving equipment andprocedures that were not functioning as intended.Because Millstone Unit 3 did not operate during theentire monitoring period, we were unable to assess inci-dent performance. When the plant resumes operation,we will begin our monitoring.

2 Only three nuclear plants have appeared on the cover ofTime—Three Mile Island Unit 2, Chernobyl Unit 4, andMillstone Unit 3.

However, before beginning our current monitoring pro-gram, UCS had examined the problems that causedMillstone Unit 3 to shut down. We found that the planthad operated for many years with serious flaws in itsauxiliary feedwater and recirculation spray systems. Inorder to cool the reactor core sufficiently during anaccident, the auxiliary feedwater system must provideadditional water to the steam generators to replacewater lost through the accident. Damage to this vitalsystem contributed to the severity of the Three MileIsland accident. The recirculation spray system mustoperate after an accident in order to cool the reactorcore and the containment. If this system does notoperate, radioactivity released in an accident couldescape to the atmosphere. Since these flaws wentuncorrected for a long period, people living nearMillstone may have been protected as much by luck asby the plant’s safety features.


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The Duke Power Company operates Oconee Unit 1.The plant, located 30 miles west of Greenville, SouthCarolina, has a generating capacity of 846 megawatts.Unit 1 is a pressurized water reactor supplied by theBabcock & Wilcox Company. Duke Power also oper-ates two other units at Oconee, as well as four plantselsewhere.

Operating License Issued: February 6, 1973License Expiration Date: February 6, 2013

/QPKVQTKPI�4GUWNVUOconee’s average incident performance score was sig-nificantly better than that of the focus group. Oconeewas the only focus group plant that identified everyreported problem at the first or second opportunity. Onaverage, focus group plants identified only 82 percentof their problems at the first or second chance.

The incident at Oconee in which performancereceived the lowest score involved workers lifting mate-rial to the roof of the reactor building while the plantwas operating. The material was being stored on

the roof in preparation for an upcoming refuelingshutdown. An NRC inspector observing this workquestioned the prudence of lifting heavy loads overemergency equipment. Plant workers determined that adropped load could break a vital pipe that providesadditional water to the reactor during an accident. Thispipe can also be used to provide water to the spent fuelpool. Thus, breaking the pipe could drain the spent fuelpool, causing its irradiated fuel assemblies to becomeuncovered. The uncovered fuel assemblies, whichremain highly radioactive and still produce consider-able heat, could melt down or expose plant workers tomore radiation than allowed by health regulations.

Because Oconee’s general performance was con-sistently strong, this incident suggests that the staff’sapproach to temporary plant activities lacks the rigorthat they apply to routine activities. Poor oversight oftemporary activities has long been an industry problem.Oconee’s owners need to prevent similar problems byextending their effective control over day-to-day opera-tions to temporary activities.

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Incident Performance at Indian Point 3Nuclear Power Plant


The GPU Nuclear Corporation operates the OysterCreek nuclear power plant. This plant is 9 miles southof Toms River, New Jersey. It has a generating capacityof 619 megawatts. Oyster Creek is a boiling water reac-tor with a Mark 1 containment supplied by GeneralElectric. It is the oldest operating nuclear plant in theUnited States. GPU Nuclear also operates the ThreeMile Island Unit 1 plant and operated Three Mile IslandUnit 2 until its accident.

Operating License Issued: July 19, 1974License Expiration Date: July 19, 2014

/QPKVQTKPI�4GUWNVUThe average score for incident performance at OysterCreek was significantly better than the focus groupaverage. The proactive behavior of plant staff isparticularly praiseworthy. They discovered 11 percentof the plant’s problems by reviewing problems reportedby other plants and then checking to see whether they

existed at Oyster Creek. On average, focus group plantsidentified only 3 percent of their problems through suchproactive efforts. These initiatives earned Oyster Creekone of the top five incident performance scores amongthe focus group.

Another indication of Oyster Creek’s effective self-assessment was that they found most of the reportedproblems themselves. The NRC found only 8 percent oftheir problems, compared with a 15 percent averageNRC discovery rate across the focus group.

On the other hand, Oyster Creek was not free fromserious problems. In September 1996, workers mistak-enly dumped 133,000 gallons of slightly radioactivewater into Barnegat Bay. This volume of water tookhours to leave the plant, during which time variousworkers missed several opportunities to detect and stopthe flow. The volume of water discharged to the bayrepresents about half the capacity of the tank it camefrom. Too many workers missed this problem for toolong.

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Entergy Operations Incorporated operates the RiverBend nuclear power plant, which is located 24 milesfrom Baton Rouge, Louisiana. This plant, which has agenerating capacity of 936 megawatts, is a boilingwater reactor with a Mark 3 containment supplied byGeneral Electric. Entergy acquired River Bend in amerger with Gulf States Utilities, its builder and initialoperator, nearly 10 years ago.

Operating License Issued: November 20, 1985License Expiration Date: August 29, 2025

/QPKVQTKPI�4GUWNVUThe average performance score for incidents at RiverBend was slightly below the average for the focusgroup. Over the monitoring period, workers caused68 percent of River Bend’s problems, compared with 35percent across the focus group. This is an alarming rateof worker error. On the plus side, performance

during one incident at River Bend received one of thebest five scores, for identifying faulty parts and notify-ing another plant that had also received the parts. Andtesting activities revealed 27 percent of the problems atRiver Bend, compared with only 15 percent for thefocus group as a whole.

Despite a testing program that appears to be gener-ally effective, one serious incident at the plant involvedtesting. In December 1995, the pump cooling the poolin which spent fuel is stored failed a test. Entergydeemed this failure acceptable because the pool’s tem-perature was below specified limits. However, thepump also failed the next two times it was tested. In1996, the NRC asked whether the pump could cool thepool when ambient temperatures peaked. Workers thenfound that the pump would not have provided adequatecooling under such circumstances. Thus, even thoughthe testing program clearly indicated the problem, RiverBend’s staff tolerated this unsafe condition.

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The Tennessee Valley Authority operates SequoyahUnit 1. The plant, which is 10 miles northeast ofChattanooga, Tennessee, has a generating capacity of1,117 megawatts. Unit 1 is a pressurized water reactorsupplied by Westinghouse, featuring an ice condensercontainment design. The Tennessee Valley Authority, afederal agency, also operates a second unit at Sequoyah,as well as four other nuclear power plants.

Operating License Issued: September 15, 1981License Expiration Date: September 15, 2021

/QPKVQTKPI�4GUWNVUThe average score for incident performance at Sequo-yah made it the lowest performer of any of the focusgroup plants. The most troubling finding was that the

NRC, not the staff, identified many of the problems.The NRC found 30 percent of the plant’s problems,compared with only 15 percent for the focus group as awhole. This suggests that Sequoyah’s self-assessmentprograms are ineffective.

Another disturbing finding was that maintenanceactivities caused 26 percent of Sequoyah’s problems,compared with a focus group average of only 9 percent.Clearly, maintenance needs considerable improvement.

Sequoyah also compared poorly with the focusgroup average on problems caused by worker error(48 percent compared with 35 percent) and poor proce-dures (56 to 44 percent). These should be the easiestproblems to prevent, particularly at a plant that hasbeen operating for nearly 17 years.

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The Virginia Power Company operates Surry Unit 1.The plant is located 17 miles northwest of NewportNews, Virginia. It has a generating capacity of801 megawatts. Unit 1 is a three-loop pressurized waterreactor supplied by Westinghouse. Virginia Poweroperates a second unit at Surry and two additionalnuclear power plants.

Operating License Issued: May 25, 1972License Expiration Date: May 25, 2012

/QPKVQTKPI�4GUWNVUSurry had the best performance of any focus groupplant. Plant staff did not rely on the NRC to identifyproblems at the plant. The NRC found none of thereported problems, as compared with 15 percent of the

problems across the entire focus group. Just as impor-tant, Surry workers identified problems at the firstopportunity 69 percent of the time, compared with afocus group average of 58 percent. Staff error causedonly 20 percent of the problems, compared with35 percent across the focus group. These are strongindications of good performance.

Plant incidents revealed 19 percent of the problemsat Surry, compared with a focus group average of29 percent. These data suggest that the workers at Surryeffectively seek out and prevent potential problemsrather than waiting for something to happen. “Don’t fixit if it ain’t broke” may be a catchy slogan, but “Fix itbefore it breaks” is a much better policy from a nuclearsafety perspective.

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6*’ 6*’ #& #0& 6*’ ).; - union of concerned · pdf filecalvert...

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6’ 6’ #& #0& 6*’ ).; - union of concerned · pdf filecalvert...