Situation

During the crucial few seconds after the initial mechanical failure which caused the 1979 accident at Three Mile Island, operators were overwhelmed by the number and variety of alarms and thus missed the brief window of opportunity to prevent further damage. The confusing array of controls and displays makes future accidents more likely.

Diagnosis

In the wake of the accident, the Nuclear Regulatory Commission (NRC) mandated a detailed review of nuclear power plant control rooms nationwide. David is appointed to an industry task force charged with evaluating the control rooms at six plants.

Task force members

• Interview plant operators
• Perform operational tasks
• Study procedures and checklists

It becomes apparent that there are gaps in operator training, and in procedures.

Solution

Task force recommendations include:

• User-friendly operator controls and displays
• Revising thousands of procedures for standard and emergency operations
• Hands-on simulator training for control room operators based on new emergency procedures and scenarios.

David is engaged to bring one plant into compliance. He asks for and receives a budget of $10 million. The corrections are implemented on schedule and under budget.

Results

After two years of analysis and implementation, all corrections pass the NRC’s detailed audit on the first attempt. In more than 30 years since the Three Mile Island accident, there has not been another major incident at a U.S. nuclear power plant.