ASHINGTON, Nov. 19 — In a confidential report, the
nuclear industry's internal oversight group has warned
utilities that a focus on production over safety had
endangered an Ohio reactor and could be a broader problem
around the nation.
Corrosion at the Ohio reactor, discovered in March, ate
away 70 pounds of steel and left the reactor vessel vulnerable
to rupturing. But while the physical degradation of the
reactor was unique, the internal report suggested that the
causes might not be. The report, not intended for distribution
outside the nuclear industry, said the the First Energy
Nuclear Operating Company, operators of the reactor, Davis-Besse, near Toledo, had
fallen prey to "excessive focus on meeting short-term
production goals" and "a lack of sensitivity to nuclear
safety."
"The lessons learned from the Davis-Besse event are
universal in nature and should be reviewed by all nuclear
stations," said the report, by the Institute of Nuclear Power
Operations, a group formed by the industry after the March
1979 accident at Three Mile Island, Pa., to share expertise
and reduce the chance of further meltdowns. The report is
marked "limited distribution" and is coded "Red: Immediate
Attention."
For several years, outside critics have raised alarms about
a deregulated power market, saying managers would cut corners
to keep reactors operating when they should have been shut for
maintenance. Even the chairman of the Nuclear Regulatory
Commission raised that concern, in 1994.
At Davis-Besse, in Oak Harbor, about 25 miles east of
Toledo, managers postponed taking the time to inspect an area
on the vessel head that turned out to be corroding, and
ignored warning signs that this was happening, the report
said.
The industry has not publicly admitted to any worry, nor
seized the Davis-Besse incident as a warning. The new report,
however, recommended that each nuclear company "conduct a
self-assessment to determine to what degree your organization
has a healthy respect for nuclear safety and that nuclear
safety is not compromised by production priorities."
The institute has a quasiregulatory function, bringing
lagging reactor operators up to the industry standard as a way
to head off tighter rules from the Nuclear Regulatory
Commission. After the meltdown of the reactor at Three Mile
Island, in March 1979, the industry created the institute to
investigate problems at each plant and to issue confidential
reports to the others, so they all could benefit from lessons
learned. Operators of all the nation's power reactors are
members of the institute, and on the intermittent occasions
when its internal assessments become public, they have all
been written in blunt terms. Industry executives say its
pronouncements are carefully read.
This one, nine pages plus footnotes, was made available by
a nuclear industry expert who is seeking to have the industry
take it to heart.
A spokesman for the institute, Terry Young, said its
personnel could get access to the plants, and state their
findings plainly, only if everyone agreed that the findings
should be kept within the industry. "We cherish that sense of
trust," he said.
Mr. Young said the reports did, in fact, discuss management
issues when that was relevant.
The report, dated Nov. 11, cites one failing that seems to
show that Davis-Besse's operators had not learned to benefit
from other failures. In a July 2001 report to members, the
institute emphasized the importance of inspecting for
corrosion after a less severe problem was found at a similar
plant in South Carolina, Oconee. The institute said managers
suffered from "isolationism."
The Oconee report was "reviewed and accepted" by management
at Davis-Besse, the institute said, but managers did not
perform the inspection on their own plant.
A year ago, even as the steel was being eaten away, the
plant's operator was seeking permission to raise its power
output by 12.9 percent above what it was licensed for when it
opened in 1978.
Experts not involved in the preparation of the report said
that it touched on a difficult area, determining when
priorities have been put in the wrong order and people's
attitudes have shifted away from safety and toward production,
and that this report differed from most written by the
institute because it focused on upper-level management.
"Talking about management is very sensitive for them," said
Andrew C. Kadak, the former president of the Yankee Atomic
Electric Company, an umbrella company for three reactors, and
a professor at the Massachusetts Institute of Technology.
At the Union of Concerned Scientists, a watchdog group that
is generally critical of the industry, David Lochbaum, a
nuclear expert, said measuring attitudes toward safety was
hard for people in the industry.
"Most of the nuclear industry's people are engineers," Mr.
Lochbaum said. "They love equations, things they can measure.
But safety culture isn't something you can do that on; you
can't see how many feet of safety culture you have and whether
you've come up shy or not."
Paul Blanch, a nuclear safety consultant, said that for
"merchant" plants, the ones selling their production in
deregulated markets, "their only concern is making money."
Mr. Blanch said the institute's report "hit the nail on the
head."
"Production does come before safety," he said. "They've got
to strike the proper balance."
An engineer at a nuclear plant that was shut for safety
reasons for a time in the 1990's, who would not allow his name
to be used, said the report was a shift for the institute,
which began by trying to share best practices around the
industry, and later on human performance, but which is now
focused on leadership performance.