COVER:
A heat-sensitive DOE photograph of Three Mile Island taken on the eighth day of the accident. Yellow areas
are at a higher temperature.

Available fromGPO Sales Program
Division of Technical Information and Document Control
U.S. Nuclear Regulatory Commission
Washington, D.C. 20555
andNational Technical Information Service
Springfield, Virginia 22161

II
three
mile
islandVOLUMEPart 3

A REPORT TO THE
COMMISSIONERSAND TO THE
PUBLICMITCHELL ROGOVIN
director

GEORGE T. FRAMPTON, JR.
deputy director
NUCLEAR REGULATORY COMMISSION
SPECIAL INQUIRY GROUPAVAILABILITY OF
REFERENCES
The documents cited in this volume are primarilyof four types:

The NRC documents cited in this volume that areavailable in the PDR consist of the following:

1. NRC-originated material or material presented toor developed for the NRC
2. Material developed by or for other Federal andState bodies
3. Open literature publications consisting of copyrighted books, magazine articles, newspaper clippings, national and society standards, and othersociety publications (transactions, conference
proceedings, reports, etc.)
4. Publications of the United Nations

1.

2.
3.
4.
5.
6.

The NRC-originated material and that presented
to or developed for the NRC has been placed in the
NRC Public Document Room (PDR) at 1717 H Street,
N.W., Washington, DC. It is available for inspection
and for copying for a fee. Orders may be placed inperson, by mail or by telephone. Both paper copy
and microfiche can be purchased. Paper copy is 8
cents per page for standard size paper (8 X 11 Y=
i nches) and 11 cents per page for larger size paper(drawings and foldouts). Microfiche copies are 25
cents per diazo duplicate. A minimum charge of$2.00 plus postage is made for mail orders. Whenordering by telephone or mail, acknowledge a willi ngness to assume charges for all orders but do notsend payment. Orders will be processed andmailed with a bill from the PDR contractor for thisservice. The telephone is (202) 634-3274 and theaddress is
NRC Public Document Room
1717 H Street, N.W.
Washington, DC 20555

7.
8.

9.
10.

11.
12.
13.
14.
III

Dispositions (both those taken by the
President's Commission and those taken by
the Special Inquiry Group. These are indicated by name and page number.)
Memorandums and letters (internal, external
and those received by NRC and others)
Interviews (These are indicated by name andpage number.)
Regulatory Guides
Standard Review Plan (NUREG-75/087)
Technical Specifications (generic or docket
specific)
SECY papers (NRC staff papers for Commission consideration)
Commission Issuances (labeled, for example,
4 AEC 768, 6 NRC 1218, where "4" is thevolume number, "AEC" indicates pre 1975
i ssuances, "NRC" is post 1975, and "768" isthe page number. These issuances present
Commission opinions and decisions.)
ACRS transcripts and reports (Advisory Committee on Reactor Safety)
Docket material (for example, Docket 50-320
i s Three Mile Island 2. A Docket 50 file contains all materials pertinent to a specificpowerplant.)
Branch technical positions (from Office of
Nuclear Reactor Regulation)
NRC contracts (for example, NRC-05-77-044)
NRC Inspection and Enforcement Manual
Commissioner speeches

15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.

Public Announcements
Board Notifications (to ASLB and participantsin proceedings)
Transcripts of Operating License Hearings (inDocket Files)
Operating licenses and amendments (inDocket files)
NRC Management Directives (that is, Manual
Chapters)
Transcripts of NRC Commission meetings
Proceedings of Atomic Safety and Licensing
BoardsI E Circulars and Preliminary Notifications (PN)
Vendor and licensee topical reports (for example, B&W, Met Ed, and GPU reports)
NRC Inspection Reports
Meeting summaries
Plant logs, charts, data
Reference foreign documents
NUREG and NUREG/CR series reports

Congressional hearings
General Accounting Office (GAO) reports
Senate reports (S. Rep.)
Congressional Reports (Cong. Rep.)
House reports (H. Rep.)
ERDA reports
DOE reports
Federal Energy Regulatory Commission (FERC)
Dockets
I nternal Revenue Service Ruling and Bulletins(com. Bul and Rev. Rul.)
Military Specifications (Mil. Spec.)
HEW reports
National Academy of Science reports
National Council on Radiation Protection(NCRP) reports
National Laboratory Reports (Savannah River
Laboratory, Lawrence Livermore Laboratory)
EPA Manual of Protective Action Guides
Federal Response Plan for Peacetime
Nuclear Emergencies
Federal Aviation Administration
U.S. Department of LaborWASH reports (WASH-1400 and others)

Some formal NRC reports, which are listed as
NUREG-XXXX or NUREG/CR-XXXX, may be purchased over the counter at the PDR. Reports notavailable at the PDR and NRC Regulatory Guides
are best obtained by those who have deposit
accounts with the Superintendent of Documents,
U.S. Government Printing Office, by calling (301)492-7333 or writing:
Attn:

State
D.C. Circuit Court (D.C. Cir.)
Pennsylvania Consolidated Statutes(Penn. Consol. Stat.)
Pennsylvania Supreme Court (Pa. Super. Ct.)
Pennsylvania Public Utilities Commission(PaPUC) hearings and proceedings
New Jersey Board of Public Utility
Commissioners
Pennsylvania-New Jersey-Maryland (PJM)
I nterconnection Agreement
Ohio Public Utilities Commission(Ohio PUC) hearings
Ohio Statutes (Ohio St.)
Pennsylvania Emergency Management Agency

Publications Sales Manager
Division of Technical Information andDocument Control
U.S. Nuclear Regulatory Commission
Washington, DC 20555

These documents may also be purchased fromthe National Technical Information Service (NTIS).
Either write to NTIS or call the Sales Desk at (703)557-4650. The address is
National Technical Information Service
Springfield, Va. 22161

The material developed by or for other Federal orState bodies is available from the organization citedor, in the case of reports prepared by other Federal
agencies, the documents are available for purchasefrom the U.S. Government. Printing Office, theNational Technical Information Service, or the PublicDocument Room of the particular agency. The
documents cited in this volume that fall in thiscategory are the following:

The open literature publications cited may beavailable in public libraries and are, of course, available from the publisher. Documents of this type arealways copyrighted. Those cited in this volume include newspapers, books, journals, national and industry standards, and association and society transactions and reports.
The publications of the United Nations are available from that organization.

FederalActs of Congress (Public Laws)
Federal Registeriv

CONTENTS
Availability of References

i ii

Outline of Volume II, Parts 1, 2, and 3

xi

Ill.

Response to the Accident

807

A.

Utility Response809

1. Introduction

809

810

2. Plant Operations Response

810

a. Introduction and Summary
b. People Involvedc. Shift Operations Before Declaration of Emergency (4:00 a.m. to 6:55

811

a.m., March 28)

816

a.m., March 28)824

noon, March 28)827

d. First Management Involvement, Conference Call (6:00 a.m. to 6:40
e. Early Response After Declaration of Site Emergency (7:00 a.m. to
f. Offsite Activities

g. Decision to Stop Discharging Steam (1:15 p.m., March 28)
h. Key Personnel Leave for Harrisburg (2:00 p.m., March 28)

i . General Public Utilities Service Corporation (GPUSC) Activities
j . Decision to Repressurize

833

834
836
838

839

840

k. Wednesday night, March 28
I . Thursday, March 29

m. Friday, March 30: Releases of Radioactive Gas
n. Beginning of Recovery
o. Recovery
p. Diagnostic Capabilities of Plant Staff

q. Prior Planning for Early Offsite Supportr . Prior Planning for Longer Term Off site Support
s. Summary of Findings and Recommendations

v

841

842
845

846
849
851

852
852

3. Radiological Emergency Response

857

a. Introduction and Summary
b. Identification and Declaration of Emergency
c. Organization and Staffing
d. Dose Assessment and Onsite and Offsite Monitoringe. Equipment Availability and Limitations
f. Transportation
g. Communications and Notifications
h. Augmentationi . Response vs. Reentry vs. Recovery vs. Emergency Termination
j . Summary of Findings and Recommendations

857
857
859
867
870
871

a. Introduction and Summaryb. Development of Industry Supportc. Integration of Industry Support into Recovery Organizationd. Industry Advisory Groupe. Babcock and Wilcox Support Effort
f . Burns and Roe Support Effort
g. Summary of Findings and Recommendations

876
876
879
882
886
889
891

4. I ndustry Support

871
872
873
873

876

5. Reporting Critical Information to the NRC on March 28, 1979

894

6. Management Overview of Three Mile Island, Unit 2 (TMI-2)

914

a. Introduction and Summary of Conclusions
b. High Dose Rate Projectionsc. Incore Thermocouple Temperature Readings
d. The Pressure Spikee. Findings and Recommendations

a. Organization
b. Operating Experience of Key Management Personnel
c. Review Committees
d. Operational Quality Assurance Programe. Summary of Findings and Recommendations

7. The Radiation Emergency Plan-Development and Training
a. NRC Requirements and Met Ed's Planb. Plan Changes from Licensing Unit 1 to March 28, 1979
c. The Emergency Plan in Effect on March 28, 1979
d. Training Philosophy-Classroom vs. Drills
e. Training-Goals vs. Accomplishments
f . Training Effectivenessg. Offsite Agencies-Training and Interface
h. Summary of Findings and Recommendations

894
895
898
902
911
914
916
917
919
920
922

922
923
925

927
927
928
930
930
933

B. NRC Response933

1. Introduction

2. Description of NRC Emergency Response
a. Wednesday, March 28, 1979
b. Thursday, March 29, 1979
c. Friday, March 30, 1979
d. Saturday, March 31, 1979
e. Sunday, April 1, 1979
f . The Aftermath

943
943

951
955
961
966
968
vi

3. Evaluation of the NRC Emergency Response

969

Response of State and Federal Agencies (Except the NRC)

993

1. I ntroduction

993

a. Management of the NRC Emergency Response-Analysis and Findings ..
b. Evacuation Issues-Analysis and Findingsc. Summary of Recommendations for NRC Emergency ResponseC.

2. Emergency Response Chronology

a. Introduction
b. Emergency Notificationsc. Initial Emergency Responsed. Expanded Response after Friday, March 30
e. Events after Sunday, April 1
f . Long Term Recovery Phase

3. Federal and State Authorities and Responsibilities

a. Introduction
b. Federal Authorities and Responsibilities
c. Implementation of Federal Authorities and Responsibilities During the
TMI Accident
d. State, County, and Local Authorities and Responsibilities
e. Implementation of State, County, and Local Authorities and Responsibilities During the TMI Accident
f. Findings and Recommendations

4. Sheltering and Evacuation Advisories

969
978
986

995
995

995
996
997
999
1000
1 001

1001
1002
1003
1004
1007

1007

1009
1009

a. Backgroundb. Consideration of Sheltering and Evacuationc. Aftermath of the Advisories
d. Lifting the Evacuation Advisory
e. Findings and Recommendations

1010
1016
1016
1017

a . Introduction
b. State, County, and Local Planningc. Federal and Other Planning Assistanced. Assessment of Preparedness
e. The Mississauga Evacuation
f . Findings and Recommendations

1018
1019
1020
1021
1023
1024

5. Evacuation Planning Before and During the Accident

6. Other Protective Actions Considered by Officials
a. Introduction
b. Potassium Iodide
c. Food Interdiction
d. Water Supplies
e. Findings and Recommendations

1018

1027
1027
1027
1031
1032
1 033

7. Radiological Monitoring Efforts

a. Introduction
b. Overview of Agency Participationc. Brief Description of Off site Radiological Monitoringd. Findings and Recommendations
vii

1 034
1034

1035
1035
1038

8. Institutional Communications

a. Introduction
b. Notifications
c. Technical Communication Between Agencies

1039

Findings and Recommendations

1039
1039
1040
1041
1041
1043
1043

a. Agency Responseb. Findings and Recommendations

1044
1045

d.
e.
f.
g.

Particular Communications Problems Encountered
Communications Improve After Friday
Aftermath

9. Technical Support for the Plant

1044

10. Summary of Findings and Recommendations

a. Root Causeb. Sitingc. Overall Institutional Coordinationd. Overall Emergency Planninge . Evacuationf . Other Protective Actions
g. Radiological Monitoring Efforts
h. Physical Communications
i . The Act of Communicating
j . Comparison with the Conclusions of the President's Commission

D. Information Provided to the News Media at Three Mile Island

1 046
1046
1047
1047
1048
1049
1049
1050
1050
1050
1051
1057

1. Introduction

1057

3. The Credibility Issue

1068

2. Chronology

1058

4. The Multiple News Sources

5. Summary of Findings and Recommendations

1070

1073

Appendices111.1

Background on NRC Planning for Emergency Response

1077

111.3

NRC Communications Early in the TMI Emergency Response

1121

111.5

NRC Procedures for Decision to Recommend Evacuation April 1, 1979

111.2 Deployment of NRC Personnel and Management Structure
111.4

111.6

Chronology of TMI-2 Hydrogen Bubble Concerns
Esser Report

111.7 State and Federal Emergency Response-An Agency-by-Agency AccountI ntroduction

vin

1101

1129
1153
1156

1164
1164

Appendix 111.7 (Continued)

Specific Response of Federal Agencies (Other than the NRC) to TMI

1165

2. Federal Disaster Assistance Administration

1166

1. Federal Preparedness Agency

3. Defense Civil Preparedness Agency
4. Department of Energy

5. Environmental Protection Agency

6. Department of Health, Education, and Welfare
7. The White House

8. American Red Cross
10. Consolidated Rail Corporation (CONRAIL)
11. Department of Agriculture

12. Bureau of Land Management, Department of the Interior
13. Department of Defense

14. Federal Bureau of Investigation

1170

1175
1178
1180
1184
1184
1184

1185
1185
1186

15. Federal Regional Councils

1186

16. Interstate Commerce Commission1188

18. National Aeronautics and Space Administration

1188

17. Mine Safety and Health Adminstration
19. National Bureau of Standards

1188
1189

20. National Oceanic and Atmospheric Administration

1189

22. Small Business Administration

1190

21. Postal Service

23. Department of Transportation

1189
1190

Specific Response of the Commonwealth of Pennsylvania and Other States to
TMI

1191

2. Bureau of Radiation Protection

1194

1. County and Local Jurisdictions

3. Pennsylvania Emergency Management Agency
4. The Governor's Office

5. Pennsylvania Department of Agriculture
6. Bureau of Forestry

7. Pennsylvania Department of Health

8. Pennsylvania Insurance Department
9. Pennsylvania Department of Justice

10. Pennsylvania Department of Military Affairs
11. Pennsylvania State Police

12. Pennsylvania Department of Transportation
13. Pennsylvania Turnpike Commission

111.9

1168

1182

9. Civil Air Patrol

111.8

1165

14. Bordering States

Detailed Chronology of Emergency Response
Federal Legislative Developments Since TMI

ix

1191

1195
1197

1199
1200

1200
1201
1201
1201

1202
1202
1202
1202
1204

1210

I V. Safety Management Factors Germane to the Nuclear Reactor Accident atThree Mile Island, March 28, 1979
1. Introduction

1213

1 213
1216

2. Statutory Considerations

1218

3. NRCSafety Policy

1223

4. Safety Planning1226

5. Requirements and Enforcement1229

6. Safety Tasks

1237

7. Organization for Safety1239

8. Conclusions and Recommendations1242

9. Epilogue
V.

SIG Depositions and Interviews

1 247

VI.

Comparison of the SIG Recommendations in Volume II with Those of the
President's Commission and the NRR/NRC Lessons Learned Task Force1257

I dentification of Recommendations by Subject Area

1258

I ntroduction

Findings and Recommendations in Volume I I

1257

1260

1265

I ndexx

OUTLINE OF VOLUME II
PARTS 1, 2, AND 3

Part 1

Foreword
I.

Preaccident Licensing and Regulation Background

A. Licensing and Regulation of Nuclear Powerplants
B. Licensing and Operating Histories
C. Precursor Events

D. Pressurizer Design and Performance-A Case Study.
E. Incentives to Declare Commercial Operation
Part 2

II. The Accident and Its Analysis

A. Accident Chronology (Narrative Sequence of Events)
B. Radiological Releases

C. Plant Behavior and Core Damage
D. Alternative Accident Sequences
E. Human Factors

F. Environmental and Socioeconomic Impacts
Part 3Ill. Response to the Accident
A. Utility Response
B. NRC Response

C. Response of State and Federal Agencies (Except NRC)
D. News Media Interface at Three Mile Island

xi

I V.

Safety Management Factors Germane to the Accident
1.

Introduction

3.

NRC Safety Policy

2.
4.

5.
6.
7.

8.

9.

Statutory Considerations
Safety Planning

Requirements and Enforcement
Safety Tasks

Organization for Safety

Conclusions and Recommendations
Epilogue

V.

List of Depositions Taken

VI.

Comparison of the Special Inquiry Group Recommendations Contained inVolume I with Those of the President's Commission and the NRR-NRC
Lessons Learned Task Force
I ntroduction

Identification of Recommendations by Subject Area
Recommendations
Findings and Recommendations in Volume II
I ndexxii

III. RESPONSE TO
THE ACCIDENTA UTILITY RESPONSE
i dentified and corrected. The subsection on Plant
Operations Response examines the actions that theplant operators, Met Ed management, and their advisors either performed or directed during the accident; the major operating decisions that weremade and by whom; and their reasons for the decisions. The Radiological Emergency Response subsection describes the utility's implementation of theiremergency plan, including how the plant personnel
responded, what went right, and what went wrong.
The following subsection on the massive Industry
Support effort from throughout the United States
describes one of the most impressive but little publicized aspects of the accident. This effort contributed substantively in controlling the consequences of
the accident and ensuring the safe shutdown of thereactor. The Industry Support section ends the discussion of Met Ed's response to the accident.
Three other subsections address special topics related to the utility's response. Reporting of Critical
Information to the NRC discusses the results of the
SIG's inquiry into whether or not utility personnel orothers willfully withheld information from the NRC
about the seriousness of the accident; Management
Overview of Three Mile Island reviews the background of key Met Ed personnel involved in the
management and control of activities at the Unit 2
facility; and the Radiation Emergency Plan andTraining subsection discusses the plan and trainingthat governed the utility's initial response.

1. INTRODUCTIONOn March 28, 1979, because of weaknesses in
the methods used to ensure that licensed nuclear
powerplants are designed and operated safely, asmall loss-of-coolant accident that should have hadtrivial consequences progressed into a serious accident. Hundreds of thousands of people living incentral Pennsylvania were severely frightened, andtheir activities were disrupted. Hundreds of millionsof dollars of damage occurred to the powerplant.
This section of the report presents the results of
the Special Inquiry Group's (SIG's) examination of
Met Ed's response during and following the accident. By reviewing what occurred and with theadvantage of hindsight, shortcomings and failings
are identified, and corrective actions are recommended.
Each of the next six subsections address aseparate aspect of the utility's response to the accident. In actuality, the six aspects are interrelated
either through timing, personnel involved, or subject
matter. At the end of each subsection, the findings
and recommendations regarding that part of the report are presented.
Others reviewing this information may develop
additional findings and different recommendations.
This report describes what the SIG believes to be
the relevant events of the utility's response to theaccident so that weaknesses and failures can be809

also contributed to the operators' errors, are discussed elsewhere in this report.)
During a conference call from 6:00 to 6:40 a.m.,
Herbein, Miller, and others also failed to diagnose
the basic plant problems. Miller and Herbein werel acking a great deal of key information that wasavailable to the operators, such as knowledge of thethrottled high-pressure injection flow. However,they did know of one key symptom, low reactor
coolant system pressure, that could have led themto effective corrective action.
By 6:18 a.m., the core was being damaged and apartial fuel melting could have begun within less thanan hour. A combination of sound decisions by incoming supervisors and additional automatic actuations of the high-pressure injection system served
to avoid the imminent meltdown danger. At 6:18
a.m., incoming Shift Supervisor, Brian Mehler, decided to isolate the open pressurizer relief valve, stopping the loss-of-coolant. Although this only addressed part of the problem, it did avoid the immediate melting problems. At 7:20 a.m. and at 8:00 a.m.,the high-pressure injection system was again initiated automatically; some cooling water was pumped
i nto the reactor coolant system, and the fact that it
was actuated and operating was clearly indicated in
the control room. At 8:00 a.m., Miller made thesound decision to leave the high-pressure injection
system in operation; at 9:15 a.m., he decided to increase reactor coolant system pressure. Combinedwith high-pressure injection flow, this provided areasonable cooling procedure.
Although it was not fully recognized at that time,
the core was severely damaged. The plant staff
had a difficult task; there were no systems available
that had been designed to cool a damaged core andno procedures available indicating how best to attempt such cooling. The method being attempted
apparently was not working.
At 11:30 a.m., when the high pressure strategy did
not appear to be condensing the steam bubbles andrefilling the reactor coolant system with water, Miller, with Herbein's concurrence, decided to pursue a
low pressure strategy. This strategy involved venti ng through either the pressurizer relief valve, thepressurizer vent valve, or both, until the reactor system pressure was decreased to levels where thecontents of the core flood tanks could be injected
i nto the system. The strategy erroneously assumed
that, at the lower pressure, the injection of waterfrom the core flood tanks would be significant andwould cool the core. Although this assumption wasi nvalid, because only a fraction of the water in thecore flood tanks would be injected, the strategy stillmight have been effective if it were implemented inconjunction with maximum or near maximum high-

2. PLANT OPERATIONS RESPONSE
a. Introduction and Summary
The accident at Three Mile Island, which beganwith a loss-of-feedwater transient at 4:00 a.m. on
March 28, 1979, immediately involved the plant's
onshift operating staff. Members of the operating
staff not then on shift-including Gary Miller, theTMI Station Manager, and all other supervisorswere quickly involved in responding to the accident.
Company personnel other than plant staff were also
ultimately involved. Utility management above thestation manager level from the Met Ed offices in
Reading, Pa., the General Public Utility (GPU) offices
i n New Jersey, and an off site "staff" technicalgroup-the General Public Utility Service Corporation (GPUSC) engineering organization, with homeoffices in New Jersey-became involved in theoperating decisions that finally reestablished corecooling shortly before 8:00 p.m. that evening.
John Herbein, Vice President of Generation for
Met Ed, was a key utility manager; he was the company official directly responsible for the operation of
TMI. Herbein's office was in Reading, Pa. The Station Manager, Gary Miller, reported directly to Herbein. Another key individual was Robert Arnold,
Vice President of Generation for GPUSC; with an office in Parsippany, N.J. GPUSC was not responsible
for TMI at the time of the accident, havingtransferred what responsibility it had to Met Ed at
the completion of the startup and test program.
Arnold's group did, however, contain the company's
largest pool of powerplant engineering talent, which
consisted of about 85 engineers and scientists
working directly on powerplant design.
During the accident's first 2 hours, the operatingcrew on shift and the supervisors who came in toassist them, did not realize that reactor coolant was
being lost through an open pressurizer relief valve,
and thus allowed a small loss-of-coolant accident tocontinue. They severely throttled flow from the highpressure injection system. If this system had been
allowed to function automatically, as intended, itwould have mitigated the effects of the loss-ofcoolant and cooled the core. The operators' actions, which led to the severe core damage thatcharacterized the TMI accident, resulted from theirfailure to understand basic plant conditions thatwere indicated to them, or to follow appropriate procedures or prudent operating practices, any one ofwhich could have prevented the severe core damage. This demonstrated a deep and significant
weakness of the operating crew on shift. (Deficiencies in procedures and control room design, which
81 0

suggested severe core damage, and lack of information that more clearly and forcefully indicated serious core damage.
There had been no prior planning to apply theutility's technical resources and outside assistanceto an accident recovery effort, and such application
did not begin in earnest until Friday morning when it
was generally realized that significant problems still
existed. This slow start, along with the numerous
demands of recovery from the accident, led NRC officials to view the utility as technically weak in relation to the needs of the accident. However, wehave concluded that the utility, in terms of technicalcapability, is as good as the median nuclear utility.
I n the interim, because critical things did not gowrong, the lack of understanding did not materiallyworsen the physical course of the accident, except
for delaying recovery action. It did, however, increase the risk involved because appropriate contingency planning and mitigating actions were notunderway. Lack of understanding also affected the
public's perception of the accident because earlyreports indicated things were well in hand, but later
reports indicated they were not.
Beginning on Friday, when the continuing problems were generally recognized, the utility management and staff began effective action to obtain assistance, plan for contingencies, and direct daily
plant operations to eliminate the hazards. The
recovery effort was massive, involving hundreds ofpeople and many organizations. It included enoughactive involvement by the NRC and others to beconsidered a joint industry-Government effort.
I nevitably, without prior planning and practice, some
confusion and difficulties arose.
Whereas much of the responsibiity for permittinga relatively simple accident to escalate into the mostdamaging nuclear accident in the history of the industry must be borne by the operating staff and theutili ty management, many individual and corporate
actions taken in response to the accident were effective in ensuring minimal consequences to public
safety.

pressure injection flow, but instead, the operators
throttled the high-pressure injection flow again.
At 1:15 p.m., Herbein directed Miller to stopdischarging steam through the atmospheric dump
valves. This decision at first glance appeared questionable, but after evaluation, we do not consider it
unreasonable.
At 2:00 p.m., Miller, Herbein, and George Kunder,
Unit 2 Superintendent of Technical Support, left theplant for about 2 1/2 hours to brief Lt. Gov. Scranton.
Although Miller has stated that he would not havegone if he hadn't felt the plant was stable and undercontrol, we nevertheless consider his departure
poor judgment. The core was not being effectively
cooled and there was no good evidence that things
were well in hand.
Upon returning from the briefing at 4:30 p.m.,
Herbein stepped in to override the plant staff's strategy for core cooling. This decision (repressurizing
and running a reactor coolant pump) resulted in a
known stable and effective core cooling mode forthe first time since the initial accident. Herbein was
assisted by Arnold in reaching this decision. At thatti me, Arnold and his group in Parsippany had become concerned, and on their own initiative, hadgathered enough information to diagnose the basic
problem and recommend effective corrective action.
This positive intervention by utility management
was somewhat fortuitous in that no responsibilties
for reviewing operating decisions had been plannedor assigned to the management. Not all utilities
have either as large an engineering staff or executives with appropriate backgrounds to enable themto direct actual plant operations during emergencies.
Although a reasonable organization for plant
operations was improvised by the plant staff on thespot, deficiencies that result from the lack of preplanning and emergency drills were evident. (Radiol ogical aspects of emergencies had been organizedand practiced, but plant operations aspects hadnot.) Some of the key supervisors involved in theoperating decisions were not well prepared to stepi n and direct plant operations during an emergency.
There were some communication problems among
the plant staff and with outside organizations.
On Wednesday evening, March 28, with a reactor coolant pump running and core cooling established, the utility management and staff believed
things were under control. They did not recognizethat the core had been extensively damaged or thatthe reactor coolant system contained a large quantity of hydrogen, and thus did not suspect thesethreats to continued core cooling. These factors
were not fully understood until Friday, March 30.
This delay in recognition was due to not understanding the significance of some information thatb. People Involved
Plant Staff

Figure III-1 provides a simplified organization charti ndicating the key plant staff personnel involved in
Unit 2 plant operating decisions.
The shift crew on duty at TMI-2 during the earlymorning shift on March 28, 1979, included 10 operations personnel, 4 of whom had current NRC
operating licenses. William Zewe, Shift Supervisor
81 1and the person in charge of Unit 2, had 7 years of
nuclear experience at the TMI station. He had been
licensed by the NRC as a senior reactor operator
for more than 5 years. Zewe is a high school graduate with 6 years of nuclear training and operating
experience as an enlisted man in the U.S. Navy nuclear program before he joined Met Ed in 1972.
Zewe was assisted by Frederick Scheimann, Shift
Foreman, a high school graduate who had 8 yearsof nuclear training and operating experience as anenlisted man in the U.S. Navy nuclear program before joining Met Ed in 1972. Sheimann was promoted to shift foreman in 1978 and became licensed asa senior reactor operator by the NRC at that time.

Manipulating the reactor controls at Unit 2 thatmorning were Craig Faust and Edward Frederick,both of whom were high school graduates having
several years of nuclear training and operating experience in the U.S. Navy nuclear program before
joining Met Ed in late 1973. Faust and Frederick received their NRC reactor operator licenses in late1977 for the startup of Unit 2. Supporting the control room operators were auxiliary operators Donald
Miller, Terry Daugherty, Dennis Bucher, Dale Laudermilch, Steve Mull, and Juanita Gingrich. These
operators perform activities that take place outsideof the control room, such as valving operations,
testing, operational maintenance, and. equipment
surveillance. Additionally, there were four radiation
chemistry technicians and one trainee on duty thatmorning to support the operating crews at the station. With respect to the capabilities of this particular crew, Zewe's supervisor, James Floyd, Unit 2
Operations Supervisor, believed that the crews
were balanced, and that this crew was neither agreat deal better nor a great deal worse than theother five crews.
On March 28, the Unit 1 operations crew, who
would normally be under Zewe's control along with
the Unit 2 crew, were being directly supervised byanother shift supervisor, Kenneth Bryan. (Unit 1 wasin startup preparation having just completed a refueling outage. During periods of high activity it was
the station practice to assign a shift supervisor toeach reactor.) Zewe called on Bryan for assistanceshortly after the start of the accident. Bryan is ahigh school graduate who joined the Met Ed nuclear
program in 1969 as a trainee with no prior nuclear
experience. He had been licensed on Unit 1 forabout 3 years and had obtained a senior reactor
operator license on Unit 2 in early 1978. Anothershift supervisor who assisted Zewe about 2 hours
after the accident started was Brian Mehler.
Mehler's nuclear training experience and licensing
history parallel Bryan's.

Other station personnel who arrived in the control room after the accident began, but prior to thedeclaration of an emergency and activation of the
Met Ed emergency plan, included Joseph Logan,
Unit 2 Superintendent; George Kunder, Unit 2 Superintendent of Technical Support; and MichaelRoss, Unit 1 Operations Supervisor. Of these three,
Kunder was the first to arrive (at 4:50 a.m.); he was
the on-call duty officer. Kunder, a graduate
mechanical engineer from Pennsylvania State
University, had 10 years of nuclear training and experience at TMI Unit 1. He held a senior reactor
operator license for Unit 1 and was in training for alicense at Unit 2. Kunder had transferred to his Unit
2 position 3 months before the accident. Logan,
who arrived in the control room at 5:45 a.m., hadbeen informed shortly after 4:00 a.m. of the planttrip, but not of subsequent developments. Logan isa graduate engineer from the U.S. Naval Academy
with 20 years of nuclear training and operating experience in the naval nuclear program. After servingfor 30 years as a commissioned naval officer, hejoined Met Ed in a training status in early 1978. Logan obtained a senior reactor operator license on
Unit 2 in late 1978 and became the Unit 2 Superintendent 3 months before the accident. MichaelRoss was in Unit 1 when Zewe called him about
6:00 a.m. and asked him to come to the Unit 2 control room. Ross is a high school graduate with 8
years of nuclear training and operating experience
as an enlisted man in the U.S. Navy nuclear program
before joining Met Ed in 1968. Ross had held various NRC operating licenses since 1969, including asenior reactor operator license on Unit 2 since late1977. He was a shift supervisor at Units 1 and 2 prior to his promotion to Unit 1 Operations Supervisor
in late December 1978.
Although he was not a Met Ed employee, Leland
Rogers, the B&W Site Manager, should be mentioned here. He assisted the station manager on
March 28, providing advice and communications
with B&W. Rogers, a high school graduate, had 15
years of operating and instructional experience asan enlisted man in the naval nuclear program. This
career was followed by 2 1/2 years of experience intesting and startup of Westinghouse reactor plants,
after which Rogers spent 6'/2 years with B&W at
the Three Mile Island site.
Company Management and Staff

Figure 111-2 provides a simplified organization
chart indicating key company managers and staff
groups involved in plant operations and support.
A key manager was John Herbein, Met Ed's Vice
President of Generation. He was the corporate off81 4

NOTE: SEE FIGURE 111.1 FOR

ADDITIONAL INFORMATIONON PLANT STAFF

FIGURE 111-2. Key Company Management and Staff Involved in Plant Operations
and Support

i cer directly responsible for operation of the Three
Mile Island Station as well as other Met Ed generati ng stations. An engineering graduate of the U.S.
Naval Academy, Herbein's background includes
training as an officer in the U.S. naval nuclear program, licensing as a senior reactor operator on the
Saxton and TMI-1 reactor plants, and supervisory
experience at the Saxton and Three Mile Island stations. Herbein's background was significant because on the afternoon of March 28, he stepped in
to override the recommendations of the plant staff
and directed changes in the operating strategy. A
utility official, lacking a nuclear background ofHerbein's type, would be less likely to actually direct
the plant staff in this manner during an emergency.
Herbein reported to Walter Creitz, President of
Met Ed. Creitz reported to Herman Dieckamp,
President of GPU. The Three Mile Island station
manager, Gary Miller, reported to Herbein. (An inmanager, L.L. Lawyer,
Managertermediate
Generation Operations, was in the line between
Herbein and Miller for matters such as correspondence with the NRC, but not for operational
matters.) Miller is an engineering graduate of the
U.S. Merchant Marine Academy. His backgroundi ncludes experience in a shipyard as a civilian test
engineer for naval reactors and he held a senior
reactor operator license for TMI-1. Also reporting toHerbein were various Generation Division staff
groups in Reading, Pa., including those headed by
Richard Klingaman, Manager Generation Engineeri ng; and George Troffer, Manager Generation Quality Assurance.
Klingaman's group of 25 engineers was responsible for engineering support in the operation of the
TMI and other Met Ed generating stations. The
GPUSC Generation Division, in Parsippany, N.J.,
contained a larger pool of powerplant engineering
talent. It provided engineering services for the entire GPU system-Met Ed, the Pennsylvania ElectricCompany, and the Jersey Central Power and Light
Company. The primary emphasis of the GPUSC
group was on engineering new powerplants andmajor modifications to existing plants-not on engineering support for operating plants. However,when the Met Ed engineering group needed assistance in dealing with a plant problem it would usuall y consult with GPUSC, at least as a first step, before involving an architect-engineer firm. TheseGPUSC engineers reported to Robert Arnold, Vice
President Generation, GPUSC. Arnold reported toHerman Dieckamp, the President of GPU. Richard
Wilson, Director of Technical Functions, reported to
Arnold and in turn several engineering managers, including Robert Keaten, Manager Systems Engineeri ng, reported to Wilson.

Arnold's background includes training and considerable operating experience as an officer in the
U.S. naval reactor program and management of theconstruction and testing of the TMI station. Collectively, those reporting to Arnold provided a pool ofpeople with extensive experience in the design andoperation of several different types of reactor
plants.
The backgrounds of Arnold and his staff weresignificant. By the afternoon of March 28, Arnold's
staff had, primarily on its own initiative, found out
enough to become concerned and then to make
operating recommendations through Arnold to Herbein. Herbein concurred with these recommendations to repressurize the reactor coolant system andto restart a reactor coolant pump, and he directed
the plant staff to carry them out. Some utilities havesmaller technical staffs. A smaller group or a groupwith less collective experience would have beenless likely to become involved in this manner. For
example, Klingaman's Met Ed engineering group andthe small group of NRC personnel in the control
room and Region I did not diagnose that the reactor
core was not being adequately cooled. On the other hand, NRC Headquarters and B&W Headquarters, two larger groups, did diagnose the basic
problem that afternoon when they found out about
the hot-leg temperatures.
The point is that some utilities have smaller
technical staffs than GPUSC and some utility executives do not have as much nuclear operating background as do Arnold and Herbein. Thus, they would
be less likely to intervene in plant operating decisions, especially under emergency conditions. The
need for such intervention in this accident, suggests
the need for prompt action to upgrade operating
staff capabilities and to provide them with themeans for obtaining immediate expert advice fromoutside sources to backup emergency operating
decisions.
c. Shift Operations Before Declaration of
Emergency (4:00 a.m.-6:55 a.m., March 28)
BackgroundAt 4:00 a.m. on March 28, 1979, Bill Zewe, Shift
Supervisor, was sitting in the Unit 2 shift
supervisor's office doing paperwork when he heard
several annunciator alarms in the control room.
Looking out into the control room, Zewe saw
several annunciators light up on the integrated control system panel. As Zewe hurried into the control
room, he noticed that the main turbine had tripped
and then the reactor tripped. Zewe recalled that81 6

prior to the trip the "only real problem we had wasresin stuck in the line between the number 7 polish2
er (condensate polisher) and the receiving tank."(Later it was found that the outlet valves from thecondensate polishers had closed and that interrupted the flow of water in the feedwater system-thiscaused the main feed pumps to trip. A trip of themain feed pumps closes the main turbine steam
stop valves.)
Fred Scheimann, Shift Foreman, was at the condensate polisher in the auxiliary building helping
unclog the stuck resin when he "started hearing
l oud thunderous noises like a couple of freighttrains." 3 ( A phenomenon termed "water hammer"
often occurs in large pumping systems when waterflow is suddenly interrupted.) Scheimann rushed tothe control room when he heard Zewe announce"turbine trip-reactor trip" over the plant speakers.
At 4:00 a.m., Ed Frederick and Craig Faust, control room operators, were performing routine activities. Frederick recalled they had been "charging
our make-up tank inventory [borated water] to compensate for leakage that we had through the relief
valves on the pressurizer." He also said that thepressurizer spray valve was on manual operationand opened to lower the boron concentration of theborated water in the pressurizer. 4 (The pressurizer
i s a pressure vessel used to adjust the pressure in
the reactor coolant system. It is normally half-filledwith borated water with a steam bubble in the top
half. Steam leakage through any of the three overpressure protection valves, one relief and two safetyvalves, connected to the pressurizer steam space
will raise the boron concentration of the water in thepressurizer-much like boiling water in a tea kettle
will concentrate impurities.)
Plant designers knew that safety valves, if actuated to release high pressure, had a high likelihood of not completely closing when the pressure
had been reduced. The resultant leakage might
exceed NRC license limits and require a costly plant
shutdown to perform remedial maintenance in theleaking valve. To avoid the necessity for such shutdown, a relief valve designed to open at a lower
pressure than the safety valves was provided. Thei ntent was that for most pressure transients the relief valve would open and limit the pressure rise sothat the safety valves would not need to be actuated. However, the relief valve also might not closecompletely upon pressure reduction and might leakat a rate in excess of that permitted by the NRC.
However, unlike the case for a safety valve, where
NRC requirements did not permit the installation of
an intervening valve, a separate block valve was installed between the relief valve and the pressurizer.
I n this way, the valve's closure after a pressure

reduction could terminate any leakage through therelief valve if it did not fully close after its operation.
The safety and relief valve system was designed sothat the flow from the valves, whether caused byvalve operation or valve leakage, was piped to alarge collection tank-the reactor coolant draintank-located in the reactor building. The pipingfrom each of the three valves, called the discharge
piping, was provided with temperature indicatorsthat were used to detect valve leakage. Immediately
prior to the accident, one of the three valves wasleaking. The operators were not sure which one it
was because all three discharge pipes join and all
were hot. The discharge pipe temperature downstream of the relief valve was 180°F. Plant procedures required closure of the upstream valve to"block" leakage through the relief valve if thedischarge pipe temperature exceeded 130°F. This
procedure was not followed and the block valve
was left open.
Craig Faust, who had just completed recording
i nstrument readings, saw and heard the annunciatoralarms from the trip of the main feed pumps. Faust
pointed to the alarms and told Frederick, "We're introuble-something's going wrong in the plant." 5Thus began a series of events leading to a "small
break loss-of-coolant accident," which, among otherthings, ultimately led to extensive core damage,generation of huge amounts of hydrogen gas, andthe release of radioactive gases into the environment.
Small break loss-of-coolant accidents were postulated by the plant designers. To avoid fuel damage in the event of such an accident, instruments
were installed to detect the loss of coolant (sensed
by either low reactor coolant system pressure orhigh reactor building pressure), and automaticallystart the high pressure injection system. This system was designed to inject a reserve of coolant into
the reactor system at a rate of up to 1000 gallons
per minute to prevent fuel damage.
On March 28, a small break occurred when thepilot-operated relief valve atop the pressurizer
stayed open after it should have closed. (The valve
opened as it should have a few seconds after theturbine tripped when the pressure in the reactor
coolant system increased because of thermal expansion of the coolant. When the main turbine
tripped, it no longer extracted heat from the reactor
coolant system and so the coolant began to heatup. The system pressure continued to increase until i t tripped the reactor protection system, which
automatically shutdown the reactor, then operating
at 97% of its licensed power level. After shutdown,
the reactor power output remained at a few percent
of its initial output because of decay heat-energy
81 7released from radioactive decay of fission products.
The steam generator then extracted enough heat todecrease the temperature of the reactor coolant
and the reactor pressure decreased because ofthermal contraction or "shrink" of the coolant sothat the relief valve should have closed. The
preceding events happened rapidly-about 12
minutes for the entire process.)
With the relief valve open, steam escaped at a
rate of about 110 000 pounds per hour (equivalent to
220 gallons per minute of water) further decreasing
the reactor coolant system pressure. About 2
minutes after this sequence of events began, instrumentation detected that pressure in the coolant
system decreased to 1640 psig (normal pressure
was 2155 psig), which is indicative of a loss-ofcoolant accident. The instrumentation automaticallystarted the high-pressure injection system, whichthen pumped coolant into the system at a rate ofabout 1000 gallons per minute. The shift crew
quickly placed the system on manual operation andrestricted the makeup rate to about 25 gallons per
minute for the next 3 hours. Although the shift crew
observed that the reactor pressure had decreased
more than they had expected, they failed to recognize that the pressurizer relief valve was open until
Brian Mehler, the oncoming shift supervisor, pointed
it out to them at 6:18 a.m.-about 20 minutes after
Mehler arrived in the control room, Closure of theblock valve stopped the loss of coolant and pressure, but by that time too much coolant had beenl ost and the fuel elements were extremely hot andundergoing severe damage. (Subsequent studies
have shown that the block valve was closed just in
ti me. If the existing conditions had continued foranother hour a partial core melting could have begun.)
We have evaluated the critical operating decisions made by the shift crew that morning, which
worsened the outcome of the accident. These decisions involved: (1) failure to isolate the open pressurizer relief valve earlier, (2) interference with theoperation of the high-pressure injection emergency
core cooling system, and (3) shutdown of the reactor coolant pumps.
Failure to Isolate Relief Valve Earlier

Approximately 12 seconds after the main feedpumps tripped, the reactor coolant system pressure
decreased to 2205 psig-the closure setpoint forthe pressurizer relief valve. The relief valve
remained open. A few seconds later, the discharge
pipe temperature downstream of the relief valve
reached 239°F.

Between 4:04 and 4:10 a.m., the continued
discharge caused the reactor coolant drain tankpressure relief valve to lift and begin discharging
steam and water into the reactor building. The
reactor building sump pumps started and began
pumping the collected water into the auxiliary buildi ng.
At 4:14 a.m., a rupture disc at the top of the reactor coolant drain tank burst when the tank pressure
reached 192 psig. (The rupture disc provides overpressure protection for the tank for flow rates larger
than the tank relief valve can handle.)

Zewe recalled looking at the reactor coolant
drain tank monitoring panel in the control room at
about 4:20 a.m. and noticing "that the drain tank
had a high temperature and zero pressure. The
running pump [used to pump water from tank] had avery low discharge pressure [which] means that we
had ruptured the reactor coolant drain tank." 6
Zewe also noted that the reported temperature on
the discharge pipe from the relief valve was about
228° to 230°F-which was only 30° to 40°F higher
than normal-and did not indicate to him that thevalve was still open. He expected that the temperatures would exceed 300°F if the valve were open.
At about 4:30 a.m. the reactor building atmospherecoolers were shifted to fast speed to combat risingpressure and temperature in that building's atmosphere. At 4:38 a.m., an auxiliary operator reported
to the control room that both reactor building sump
pumps were running and was told to turn them off.
By 5:00 a.m., the reactor building temperature had
i ncreased from 120° to 170°F and the reactor buildi ng pressure had increased from 0 to 2.5 psig. This
resulted from the continuing discharge of high temperature reactor coolant from the pressurizer relief
valve to the reactor building, via the now open draintank. At 4:27 a.m., and again at 5:21 a.m., Zewe had
Ken Bryan, Unit 1 Shift Supervisor, obtain a computer printout for the pressurizer relief valve discharge
pipe temperature. Bryan reported a reading ofabout 228°F, but the relief valve discharge pipe temperature was actually 283°F. (During our interview,
Bryan told us that he made a mistake in reading thedischarge pipe temperature and called out the temperature downstream of a safety valve instead of
the relief valve.) At 6:18 a.m., operations personnel
again obtained a computer printout for the valve
discharge pipe temperature. This time, the pressuri zer relief valve discharge pipe temperature was
229°F, about 35°F hotter than the safety valve
discharge lines . 8 The block valve was thenclosed, stopping the leakage through the open pressurizer relief valve.
81 8

Mehler, the oncoming shift supervisor, arrived in
the control room around 6:00 a.m. He told us thatafter glancing at reactor coolant instruments, heconcluded that there was a steam bubble in the hotlegs of the reactor coolant system piping.

tors that we believe were significant are the followi ng:• The signal (illumination of a red light on a control

console) used to inform operators that the valvei s open indicated that the valve was closed. The
operator chose to believe that the valve wasclosed.
• Personnel believed that the temperature downstream of an open relief valve would be higher
than 300°F, up to 550°F. They were unaware ofthermodynamic considerations whereby expansion of the high-pressure steam exiting the relief
valve would limit the temperature of the released
steam to below 300°F. Therefore, personnel
misinterpreted the discharge pipe temper.; 'resas indicating the relief valve had opened, but actually it no longer was open.
• The signals displayed in the control room to inform the operators of the condition of the reactor
coolant drain tank, which could confirm the continuing relief valve discharge, were deficient inthat the information was displayed on instruments
out-of-view of the operator's normal work location. Neither the meters that were used todisplay the information nor the alarm system assured that the operator would be alerted to abnormal conditions in the drain tank. (The meterreadings confused the operators after the rupture
disc burst because tank pressure and level returned to near normal levels; only the temperature remained abnormal.)• Personnel were unaware of the reactor coolant
system response to a loss-of-coolant accident
from the steam space of the pressurizer. They
were unaware that steam may form elsewhere in
the system and force reactor coolant (borated
water) into the pressurizer.
• Plant procedures were ambiguous and did notprovide adequate instructions to permit theoperator to identify or cope with a small breakloss-of-coolant accident originating in the steam
space of the pressurizer. These procedures emphasized that reactor coolant pressure and pressurizer level both decrease during loss-of-coolant
accidents.
• The operating procedure required closing thepressurizer relief block valve if the relief valve
discharge pipe temperature exceeded the normal
temperature of 130°F, and again if it exceeded thealarm setpoint of 200°F. Contrary to the procedure, management allowed the pressurizer relief block valve to remain open although the temperature in the valve's discharge piping exceeded
the normal limits. This condition persisted for

I based the steam bubble in the hot leg because thepressurizer was solid [filled with borated water] andthe [reactor] pressure was low so that means there
had to be a steam bubble somewhere else, forcing
the water up into the pressurizer... I went to thecomputer and punched out the temperatures onboth the code relief [safety] valves and electromatic [pressurizer relief valve] and based on that I assumed the electromatic was leaking. 9(Mehler also recognized that such conditions could
also be caused by a loss of pressurizer heaters,
and directed others to check the heaters.) Mehler
then ordered that the block valve be closed. 10
Frederick corroborated Mehler's statement inthat he testified that the block valve was closed at
the suggestion of a shift supervisor coming in for
the next shift. However, Frederick considered thatthe valve was closed out of desperation because
they could think of nothing 11,12
else to do to bring thereactor back under control.
Thus, 20 minutes
after his arrival, Mehler made a correct decision andtook action to start bringing the reactor back into
control, too late to avoid fuel damage, but soon
enough to prevent fuel melting. Although the shiftcrew had searched for 2 hours for the cause ofwhat Frederick called "screwy plant conditions" (lowpressure in the reactor system, high water level inthe pressurizer), they were unable to diagnose theproblem. Similarly, plant staff supervisors arriving in
the control room-Kenneth Bryan, Unit 1 Shift Supervisor, 4:08 a.m.; George Kunder, Unit 2 Superintendent of Technical Support, 4:50 a.m.; and Joseph
Logan, Unit 2 Superintendent, 5:45 a.m.-were also
unable to diagnose the problem.
Although the operators' failure to isolate the relief
valve sooner involved some lack of knowledge,
some violation of procedures, and some failure tochoose the more prudent course of action, it appears to us that poor human engineering practices
i n the design and management of the facility contributed heavily to this failure. Plant instrumentation
signals displayed in the control room gave, at leasti n hindsight, abundant evidence that the pressurizer
relief valve was open; but we believe that deficiencies in the display of this information in the control
room, deficiencies in information in the control room,
deficiencies in training of the plant staff, and deficiencies in the plant procedures and management
practices all contributed to the failure to diagnosethat the relief valve was open. The contributing fac-

81 9

weeks prior to March 28. After the accident began, the operators continued violating the sameprocedure although the temperature then exceeded the higher limit as well.
. The operators could have chosen to take theprudent approach with respect to this issue, thati s, to close the block valve just in case. However, they did not do so. We believe this decision
was made because they thought the relief valve
was closed.
I nterference with High-Pressure Injection

Approximately 2 minutes after the main feedpump trip, the loss of reactor coolant through theopen pressurizer relief valve depressurized thereactor coolant system to 1640 psig, whereupon thehigh-pressure injection system was automaticallyactuated. The two high-pressure injection pumps
began injecting 1000 gallons per minute of borated
water into the reactor coolant system in accordancewith the plant design and procedures for mitigationof small break loss-of-coolant accidents. (Thiswould have replenished the coolant losses occurring
through the open relief valve.) The emergency safeguard signal was bypassed by the operator about 1
minute after the high pressure system actuated.
Bypass of the signal is required, by the TMI-2 emergency procedure for loss of reactor coolant or sys13
tem pressure, to allow the operator to limit eachpump to a flow of 500 gallons per minute. (Bypassing the signal returns control of the high pressure
system to the operator-manual operation-to permit throttling of pump flows to prevent pump"runout." Runout is a condition where a centrifugal
pump is pumping at a flow rate that "runs out"beyond its characteristic pressure-flow curve. If theflow rate is excessive, cavitation may occur anddestroy the pump impeller.) Regarding the bypass
action, Frederick gave a different reason when he
explained "We were afraid about going solid in thepressurizer and seeing high pressure spikes. I beli eve we took manual control of the ES [Engineered
Safety Features) to prevent going solid." M At theti me the engineered safeguard signal was bypassed,
the level of water in the pressurizer was rapidly approaching the high-level alarm point.
At 4:05 a.m., about 1 minute after the bypass
placed the high-pressure injection system within theoperator's control, one pump was turned off andflow from the remaining pump was sharply restricted. Additionally, the letdown flow out of the reactor
coolant system was increased so that the average
net difference between the pump flow into the system and letdown flow out of the system was 25 gal-

Ions per minute. Thus, the letdown flow exacerbated the loss-of-coolant accident condition resulting
from the open pressurizer relief valve. Zewe directed the above actions and he said:

I wanted to bypass ES so that we secure (sic) the
make-up pump [high-pressure injection pump] andshut the high-pressure injection valves after weverified that everything had lit off for the highpressure injection. ... So, I said try to go to max
letdown [160 gallons/min.] to try to letdown to holdthe pressurizer level and then we thought the pressurizer level instruments were failing so wechecked all three pressurizer levels. 16

The check of pressurizer levels was apparently
made because, in spite of the operator's efforts, thepressurizer level continued to increase and by 4:06
a.m. it appeared to be full of water (solid). (The
operators equated a "full pressurizer" with a "fullreactor coolant system." During normal conditions,the pressurizer has the hottest water in the system;
hence, any steam in the system would be above theborated water in the pressurizer. Consequently,
plant designers only provided instrumentation on thepressurizer to inform the operator of the amount of
coolant in the reactor coolant system. However, for"pressurized water reactors" with coolant above
212°F, this is only true if the coolant system has"pressurized water." The continuing loss of coolant
through the open pressurizer relief valve lowered
the temperature of the borated water in the pressurizer, which lowered the pressure in the reactor
coolant system. This depressurization continued
until steam voids formed in the reactor coolant bei ng circulated through the reactor pressure vessel
and system piping. These voids then forced wateri nto the pressurizer, keeping it full. As more andmore coolant was lost through the pressurizer andthe letdown system, the amount of steam voids inthe coolant system increased, causing reactor
coolant pressure to remain fairly constant at the saturation pressure of about 1100 psig until about 6:30
a.m.)
During our interview with Zewe, Scheimann,Frederick, Faust and other licensed operating personnel, we found that they had not received training
i n plant response to a small break loss-of-coolant
accident in the pressurizer steam space. Furthermore, the Babcock & Wilcox operations training
manuals used by Met Ed at their training center,and the TMI-2 Final Safety Analysis Report reviewed by the NRC contained no discussion or data
reflecting plant response to the aforementioned accident. Zewe said:
I did not know why the pressurizer level was indicating so high or why the pressure was holding

82 0low, but we seemed to be fairly stable. (Emphasis
added.)... With George [Kunder] and Ken [Bryan]
and Fred [Scheimann] and Ed [Frederick] and Craig[Faust] in there ... we just were trying to put ourheads together to come up with the weird indications that we had. The high-level [water level inpressurizer], and it really didn't dawn on me or anyone else at that point, that we had really transferredthat bubble. 17

able, let alone prudent, judgment when they interferred with the emergency cooling system while theknown initiating condition-low reactor coolant system pressure-persisted.
Shutdown of Reactor Coolant Pumps

Reactor coolant pumps 113 and 2B were stopped
at 5:14 a.m. At 5:41 a.m., the remaining reactor
coolant pumps 1A and 2A were also stopped, terminating forced cooling through the core. Zewe explained the following:

Previous analyses available at the NRC and B&W,
as well as precursor events, showed that plant
operators could be and had in the past been fooled
i nto turning off the high-pressure injection system
pumps during a small break loss-of-coolant accident caused by a stuck open pressurizer relief
valve. (The other operators had, however, arrived at
the appropriate corrective actions a few minutesl ater.) Met Ed's operators were unaware of all of
this. Why the Met Ed operators were not given
benefit of this knowledge and experience is anotherstory covered elsewhere in this report.
The operating decision to interfere with the highpressure injection emergency cooling system apparently resulted in part from failure to equip plant
operations personnel with the specific knowledge,
i nstruction, and plant status information relevant to al oss of coolant from the pressurizer steam space.
The evidence indicates that the operating personnel
did not know they were experiencing a loss-ofcoolant accident and that they tried to cope with thesituation. Inexplicably, however, it appears that personnel in the control room did not immediately reinitiate the high-pressure injection system after theblock valve was closed at 6:18 a.m., stopping theloss of coolant through the pressurizer relief valve.
Zewe claimed during his deposition with us on September 11, 1979 that he did indeed have "full highpressure injection on" from the time the block valve
was closed until 7:00 a.m. or so when the reactor
coolant system was repressurized. 18 This conflicts
with his earlier statements,19 however, and plantdata do not support the contention in that this pressure would have consumed about 40000 gallons ofborated water but the total usage from the borated
water storage tank was 15000 gallons between
4:00 and 7:00 a.m. 20
It is evident that Met Ed's training of the personnel was deficient, especially in the specifics of theplant's response to a leaking pressurizer relief valve;
nonetheless, we do not believe it is feasible thatspecific training, procedures, and instruments canbe provided in usable form for every conceivable situation at a nuclear powerplant. Some reliance has
to be placed on people to make reasonable decisions during unforeseen situations. We do not believe the operations personnel exercised reason-

We were looking at the temperature-pressure
curves from the coolant pumps and we started toget abnormal fluctuation in outflow instruments fromthe reactor coolant pumps. So I decided to stop
two reactor coolant pumps at this time. We wereabout ...540" average temperature at this point.
We secured two of the coolant pumps and then theflow came down to about 50% and stayed like thatfor I'm not sure how long-but a couple of minutes
anyway-and then the flow started to fluctuate
some more. Then, we secured all the coolant
pumps and then we kept on feeding with the highpressure injection pumps at this point. 21

Frederick added the following:

At the time we turned them [reactor coolant
pumps] off, they weren't pumping what they shouldhave anyway, because we had two pumps runningand only showing 60% flow. We should have had
80-90-100% flow in one loop. Because we
secured the RC pumps in the other loop, flow
should have been 100%. But it wasn't. So it
seemed like we were losing flow to the pumps. So
we turned them off ... sa

After the pumps were turned off, the then existing
condition of a partially filled reactor coolant system
could not support natural circulation (convection)
cooling. The circulating coolant was a froth of liquidand steam that removed enough heat from the fuelto prevent cladding damage. When the pumps
stopped, the liquid and steam separated; theremaining liquid in the reactor pressure vessel was
i nsufficient to cover the fuel elements. The fuel thenbegan to heat up because part of the heat being
generated by the decay heat effect was not being
removed. Cladding damage apparently occurred
over the upper 8 to 9 feet of the 12-foot long fuelrods when the clad was cooled by steam rather
than water.
The decision to shut down the reactor coolant
pumps was consistent with the equipment protection provisions of the plant operating procedures.
When reactor coolant pressure and temperature
conditions degraded, the coolant pumps worked effectively in cooling the fuel elements even though
the pumps experienced cavitation and vibration.
82 1

The operators did not ascertain the cause for theabnormal pump conditions and did not take the apparent corrective actions to restore subcooled
coolant conditions in the reactor coolant system.
Again, there is no indication that the operators knew
the basic theory of pressurized water reactors, thatis, hot reactor coolant remains as a liquid only bykeeping the pressure up-as in a household pressure cooker.

The question of how the block valves came to beclosed has been investigated by Met Ed, by the
NRC-IE investigation, and by the President's Commission. The President's Commission staff reporton this subject summarized the other two investigations and added its own evaluation in order to express the then-current state of knowledge on thismatter. Several possibilities were explored but theactual cause of the valve closure was not determined. We have little to add, but will summarize thefour possibilities that the President's Commission
staff report listed as the most likely reasons for thevalves being closed. The interested reader is re22
ferred to the President's Commission staff report
and to the NRC-IE investigation report 23 for further
discussion.
The first of the likely possibilities listed by the
President's Commission staff report is that thevalves were left closed after a surveillance procedure that was performed about 42 hours prior to
the accident. Those who performed the surveillance
have stated that the valves were not left closed.
The improper condition would have had to go unnoticed by the control room operators during several
shifts in order for this to be the reason. However, it
is possible that the maintenance crew is mistaken.
No records indicating reopening were retained. It isalso possible that monitoring of the control boards
during intervening shifts was so sloppy that the condition went unnoticed.
The second possibility listed in the staff report isthat the valves were mistakenly closed by the control room operators during the very first part of theaccident. This could have been a simple mistake.
Alternately, it could have been a deliberate but
unauthorized part of the normal strategy to limit thepressurizer level and reactor coolant pressure decrease following a turbine trip. Blocking auxiliary
feedwater flow, by closing the block valves or bysome other means, could stop the cooldown andthus limit the pressurizer level and pressure drop.
There are indications that24this may have been doneon previous reactor trips.
The operators that were on duty when the accident occurred have denied any knowledge of sucha practice, however. 25 No evidence has been foundi ndicating that the emergency feedwater flow was
blocked at the beginning of the transient in order toli mit the pressurizer level and pressure decrease.
(Furthermore, the lack of anomalies in the record of
the emergency feedwater pressure from the control
room recorder chart indicates that ff such action
took place, it took place prior to about 36 seconds
into the accident, which is possible but quite fast.)
The third possibility listed in the staff report isthat the valves were mistakenly closed from a con-

Other Actions

Three other early operator actions that have received some notoriety are discussed briefly below.
Because these actions have been addressed byother investigations and none of them materially altered the physical course of the accident, we havenot analyzed them in detail.
Closed Emergency Feedwater Block Valves

One highly publicized operating error was theearly blockage of emergency feedwater flow to thesteam generators by two improperly closed emergency feedwater block valves. The blockage lasted
until 8 minutes into the accident, when a Unit 1 shift
supervisor who had come into the Unit 2 control
room, and the Unit 2 operators diagnosed the problem and opened the valves.

The 8-minute blockage had only a minor directmaterial effect on the physical course of the accident. It made the reactor coolant system hotter
and thus boiling occurred earlier than it otherwise
would have. However, with the pressurizer relief
valve remaining stuck open and the high-pressure
i njection flow remaining throttled, the boiling andeventual core damage would have occurred anyway.

Along with many other factors, the blockage
might, however, have helped to confuse the operators. Lacking emergency feedwater flow, the steam
generators boiled dry and stopped removing substantial amounts of heat from the reactor coolant
system about 1 minute into the accident. This
stopped the reactor coolant system cooldown,
which in turn caused pressurizer level to stop decreasing and to increase faster than it would haveotherwise. When the pressurizer level appeared tobe recovering the operators took their normal
actions-throttling high-pressure injection flow-in
response to the increasing pressurizer level. During
this time, the more rapid recovery of pressurizer
level and subsequent throttling actions, or simply
finding the block valves closed, might have helped
to confuse or distract the operators.
82 2trol point outside the control room. This was considered possible but remotely so. The fourth possibility, which is also listed in the staff report as remote, is that the valves were closed on purpose tocause trouble. No evidence has been found for either the third or fourth possibility. Other possibilities, such as control circuit malfunction, have also
been investigated but were considered even lessli kely in the President's Commission staff report.

would not have injected any significant amount ofwater. However, closing of the valves would becontrary to emergency core cooling system (ECCS)
procedures because a loss-of-coolant accident was
i n progress. Further discussion is provided in the26
NRC-IE investigation report.
Weakness of Shift Crew

There were two significant abnormalities in plantstatus that adversely affected reactor safety followi ng the turbine and reactor trip at 4:00 a.m.: theemergency feedwater system flow was blocked byclosed valves and the pressurizer relief valve wasopen.
The operating crew on shift was able to diagnoseand correct one of these abnormalities, the blocked
emergency feedwater flow, within 8 minutes after
the turbine and reactor trip. This adjustment wasmade despite the handicap of numerous alarms, indications, and actions to be taken, which competed
for the attention of the operators. The operators did
not, however, diagnose the open pressurizer relief
valve or respond correctly to the loss of coolantthat resulted therefrom.
During the first 2 hours of the accident, theoperators made two basic errors that led to thesevere core damage-failure to quickly isolate theopen pressurizer relief valve by closing its block
valve and failure to continue automatic operation of
the high-pressure injection system. Either rapid
i solation of the relief valve (within a few minutes) orallowing the high-pressure injection system to perform its automatic safety function (within 1 % to 2
hours) would have prevented the severe core damage and thus, the consequences of the accident as
we now know them.
These mistakes resulted largely from failure tounderstand the significance of basic information thatwas indicated to the operators and was consideredby them over long periods of time. Proper understanding should have led logically to one or both of
the appropriate corrective actions. Alternately,
failure to understand basic plant conditions contributed to not following appropriate procedures orgood operating practice. Existing procedures, if followed, would have led to both of the appropriate
corrective actions. Reasonably good operating
practice would have dictated allowing a safety device (the high-pressure injection system) to continuefunctioning since the condition that caused its actuation (low pressure) was still present.
Of the two basic mistakes, the throttling of highpressure injection flow was the more significant.
The particular path for the loss-of-coolant accident
that occurred happened to be isolatable, if properly

Diesel Generator Lockout

The plant's emergency diesel generators will
start automatically upon a loss of offsite power tothe plant's safety circuits or when the safety
features (such as high-pressure injection) are automatically actuated. When the high-pressure injection system actuated automatically at 2 minutes into
the accident, the emergency diesel generators
started but did not assume any electrical load because the emergency circuits were still being
powered from offsite power. Since offsite power
had not been lost, the operators stopped the diesel
generators, as required by procedures, to prevent
damage that might occur from sustained operation
without load. The diesel generators should havethen been left aligned for further automatic starts ifneeded.
However, on the basis of an unjustified assumption that offsite power would be available, and toprevent further unnecessary starts in the event offurther safety system actuations, the diesel generators were disabled by blocking the fuel supply to theengines. This left the diesels unavailable for automatic starting in the event of a loss of offsite
power. Manual starting, by restoring the fuel supply,
would have been time consuming and many of theoperators did not even know the fuel supply was
blocked. At about 9:30 a.m. an electrical engineer
noticed this condition and had the fuel supply restored. Switches in the control room were still used
to block automatic restart, but if offsite power werel ost, the diesels could have at least been started
quickly from the control room.
Core Flood Tank Isolation

At about 6:00 a.m., when the reactor coolant
pressure was about 800 psig and decreasing, thecore flood tank isolation valves were reportedly
closed. The core flood tanks were normally maintained at 600 psig and this action was supposedly
taken to prevent the tanks from injecting water into
the reactor coolant system.
This action would have made no difference to thecourse of the accident because the core flood tanks
82 3

diagnosed, but another leak path might not havebeen. A more fundamental shortcoming is the inability to tell that there is a loss of coolant occurring
at some point in the system or, lacking that, theunderstanding that it is important to keep the pressure above the saturation pressure in a pressurizedwater reactor.
Admittedly, the operators were confused by the
expectation that pressurizer level would drop during
a loss-of-coolant accident and by a desire not to fill
the pressurizer solid. Furthermore, with many
alarms going off we do not criticize the operators'
failure to diagnose anything for the first 20 minutes
or so. However, this went on for a much longer
ti me, and the symptoms were well known and continuously considered.
I n addition, throttling the high-pressure injection
flow demonstrated a basic disregard for safe andprudent operating practice. A safety device had actuated and the actuation signal, low pressure, wasstill present, yet it was immediately overridden
without careful consideration of whether or why low
pressure might be needed. Again, the operators
were misled by a procedure to immediately starthigh-pressure injection after a turbine trip to avoid
excessive pressurizer level shrink. it was naturalthen to terminate the high-pressure injection flow
after pressurizer level had been recovered. However, the severe throttling of injection flow continued
for a long time although the symptoms of the basic
problem were well known, clearly evident, and underconsideration.
The failure to understand basic plant status information and the failure to follow appropriate required
procedures or safe and prudent operating practices(any of which would have terminated the accident
with negligible consequences) indicate significant
weaknesses in the knowledge, training, capabilities,
and discipline of the operators on shift, at least withrespect to fundamental plant safety concepts. To
be sure, poor human engineering practices c-)ntributed to the accident. These practices provided a
set of complex and confusing procedures, a complex and confusing control room, and ill-considered
procedural remedies for engineering problems.
One such area that we consider to have contributed directly to the incapability on the part of theshift crew was the crew's size. Only four licensed
operators were available to pay attention to themany alarms and pertinent indications that exist
during accidents and transients, to look after morethan two dozen complex control panels, to take appropriate actions, to supervise and make basic
safety decisions, and to perform required notifications of offsite organizations. The crew size needed

for these activities could not be determined without
a task analysis that considered a particular plant's
design and the training, background, and capabilitiesof the personnel. However, four operators seem to
be clearly inadequate for handling an accident in the
TMI plant. Whereas this number exceeded the
NRC's requirements, the requirements also appear
i nadequate. Further discussion on requirements forminimum shift crews is provided elsewhere in thisreport.
Overall, the weakness evidenced at TMI-2 withrespect to basic plant safety considerations appears to be fundamental and deep. We view thisweakness as a problem within the system thatdesigned the plant, developed the operating andemergency procedures, trained the crew and set its
size, licensed the facility and the operators, approved the overall operations staff, and placed thepeople there that morning.
d. First Management Involvement, Conference
Call (6:00 to 6:40 a.m., March 28)
BackgroundManagement's first involvement came when Herbein, who was in Philadelphia, participated in a
conference call with Miller and Rogers, at theirhomes, and Kunder, in the control room. This calllasted from about 6:00 to 6:40 a.m. on March 28,
1979. Rogers was the B&W Site Manager, andKunder was the Superintendent of Technical Support for TMI-2.
Miller initiated the conference call. He had initiallybeen notified of the plant trip shortly after it occurred at 4:00 am. At 5:15 a.m., having heard nothi ng further, Miller called the plant. He was informedthat the engineered safeguards system had actuated, the pressurizer level was high, and the reactor
coolant system pressure was low. He did not consider the engineered safeguards actuation, by itself,
to be unusual following a turbine and reactor trip.
However, high pressurizer level combined with low
reactor coolant system pressure was consideredanomalous and cause for concern. He called up
Seelinger and Shovlin, informed them that Unit 2
had a problem, and told them to report to the site assoon as possible. Miller then initiated the conference call with Herbein, Rogers, and Kunder.
When the call began at 6:00 a.m., Kunder had
been in the control room for a little more than anhour. Joseph Logan, the Unit 2 Superintendent,
was nominally in charge. He had been in the control
room for a few minutes and was engaged in deter82 4

mining the plant status. Kunder participated in theconference call from the glass enclosed shift
supervisor's office in the back of the control room.
Apparently, control room personnel including Logan,Ross, and Mehler were not generally aware at theti me that Kunder was briefing the others. 27 At theti me, Kunder had not diagnosed the true
problems-a loss-of-coolant accident with throttled
high-pressure injection flow. Kunder's lack ofunderstanding of the true problems and his isolationfrom the control room operators during the call appear to have contributed to a lack of reporting somesignificant information.
The pilot-operated relief valve (PORV) was stilldischarging reactor coolant into the reactor building.
This valve was isolated later, during the conference
call, by closing its block valve at 6:18 a.m. The lossof coolant through the open pressurizer relief valve
had depleted the reactor coolant inventory and thereactor coolant system contained significant quantities of steam.
The last pair of reactor coolant pumps had been
off since 5:41 a.m. The control room operators wereattempting to establish natural circulation core cooli ng flow. Natural circulation was the only accepted,
analyzed, and qualified means of providing coolingwater flow through the core when the reactor
coolant pumps were not running, assuming thecorrect reactor coolant volume had been maintained. This effort was failing because steam (andlater hydrogen gas) in the reactor coolant system
was blocking natural circulation flow. Previously,
while they were still running, the reactor coolant
pumps had forced sufficient cooling flow through thecore despite the steam content, which was degradi ng pump performance and coolant effectiveness.
Core damage was beginning and proceeding duri ng the conference call, so it was too late to completely preclude core damage. However, had theactual plant situation been diagnosed and hadcorrective action-such as full high-pressure injection system flow-been prescribed, the amount ofcore damage could have been limited. Subsequent
problems with core cooling caused by physical coredamage and hydrogen generation also could havebeen reduced.

it was the single PORV that had stuck open andcaused this, not the opened code safety valves).
Furthermore, the reactor coolant system was at al ower pressure than expected, the reactor coolant
pumps were shutdown, the plant had been taken
solid (pressurizer full of water rather than being
about half-full of steam), and it was believed that
this was due to high pressure injection. Moreover,the pressurizer level was at 370 inches, the reactor
coolant pressure was at 700 psi, and the reactor
coolant temperature was 500°F. The emergency
feedwater system was in use to promote natural circulation, and feedwater to the B steam generator
had been secured becauseof a suspected tube
28,2s
leak in the generator.
The participants discussed the possibility that thepressurizer level reading might be false. It was decided that the instrument readings should be believed. One participant recalled mention of a waterlevel in the containment sump but would not consider that surprising with the reactor coolant drain tankrupture disc blown (as had happened before at
TMI-2 and other plants). There was no discussionof the 8-minute delay in obtaining emergency feedwater flow. (The delay had been caused by two improperly closed valves, which were discovered andopened about 8 minutes into the transient.) Kunder
was not aware of this at the time of the call. The
participants did not recall any discussion of the factthat high-pressure injection had been throttled,
although Kunder was aware of this at the time of thecall. The participants agreed that it was desirable tostart the reactor coolant pumps to reestablish
forced cooling flow through the core. Miller andRogers were to report to the site.
This action may seem reasonable assuming nogreat problems in the plant. However, we now
know that the conference call participants did notunderstand the real situation.
Points Missed
Pressure and Temperature Relationships

The reactor coolant system pressure and temperature were reported as 700 psi and 500°F,
respectively, which was an accurate representationof the conditions that existed a few minutes before
the conference call. Considering the accuracy of
the instruments, and the fact that higher coolant
temperatures would exist in parts of the core, thisi ndicated boiling in the reactor coolant system. At
700 psig, pure water boils at 505°F. (During theconference call the hot-leg temperature rose
dramatically, but this was not reported.)

Discussion and Decisions

During the conference call, basic plant conditions
were described as the following: both main feedpumps tripped, the condenser hotwell flooded, thereactor tripped on high pressure, and the reactor
code safety valves opened causing the rupture discon the reactor coolant drain tank to burst. (Actually
82 5One of the most basic concepts in a pressurizedwater reactor, indeed the source of its name, is tokeep the pressure above the boiling point for thetemperature that exists. This keeps the coolant in ali quid phase, preventing the water from boiling tosteam. If steam is formed in large quantities because of high temperature, low pressure, or both,the steam will be less effective in removing heatfrom the core and the core may be overheated.
The participants realized that reactor coolant
pressure was anomalously low and inconsistent withpressurizer level. However, they neither pursued
the significance of the low pressure to the point ofrealizing that it implied bulk boiling in the reactor
coolant system, with the attendant core coolingproblems, nor did they check to see whether or not
the pressure was low enough to cause a problem.
Had the implications been realized in terms of boili ng, corrective action could have been taken to increase the pressure with the high-pressure injection
pumps and thus, stop the boiling and condense thesteam.
The participants did not pursue an explanation
for the low pressure in order to find the cause-thestuck-open relief valve. Had this cause (which is bydefinition and in effect a small loss-of-coolant accident) been determined, the corrective action would
have been to ensure that the high-pressure injection
system was operating, since the system's specificpurpose is to mitigate small loss-of-coolant accidents.
Natural Circulation

The conference call participants decided to restart the reactor coolant pumps. They considered
this a desirable or preferable operating mode, but,
not realizing that natural circulation was not working,they did not consider this or any other action to bea drastic necessity. 30
Running the reactor coolant pumps to provide
forced cooling flow through the core immediately
after any reactor shutdown is a more normal andprudent operating mode. Natural circulation is considered a backup means. However, if natural circul ation is working it does provide adequate corecooling and makes it unnecessary to run the reactor
coolant pumps. On the other hand, if natural circul ation is blocked for some reason (the case that was
actually developing in the plant), then the situation
requires that, if core damage is to be avoided or limited, some cooling means must be found.
The participants did not recall any discussion
about whether or not natural circulation was working. They did not receive any data that would cast
doubt on natural circulation (other than low reactor

coolant system pressure). This lack of informationi s significant because, if the question had even beenraised, it could well have led to information casting
serious doubt on natural circulation and warranting
extreme concern and action to establish core cooli ng flow.
As discussed in the preceding section, the reactor coolant pressure and temperature indicated boili ng and attendant problems with core cooling. Asidefrom being a less effective coolant, quantities ofsteam, if present, are likely to block natural circulation flow. For this reason there are procedural restrictions on the pressures and temperatures atwhich natural circulation is to be attempted. The
plant was, at the time, well outside those restrictions.
When the conference call began, the actual reactor coolant system hot- and cold-leg temperatures
had begun diverging, indicating differences of 59°
and 24°F in the A loop and B loop, respectively.
These differences would not be startling. At theconclusion of the conference call, the temperature
differences had increased to about 300°F, with hotleg temperatures of about 720° and 780°F in the
two loops, respectively. These data, which were
not reported, indicated more clearly and forcefully
the failure of natural circulation and the presence ofsuperheated steam in the hot legs. (Much later inthe day when offsite agencies such as GPU engineering, B&W Headquarters, and NRC Headquarters found out about the hot-leg temperatures, they
were readily able to diagnose the significance of thetemperature readings.)
The B steam generator pressure had dropped toa very low level of about 40 psi at 6:00 a.m. andremained there during the call, indicating virtually noheat transfer into that generator. The A steam generator pressure had dropped to about 700 psi atthe beginning of the call and to about 400 psi at theend of the call, indicating little heat transfer to thatgenerator. This information, also not reported,
raised considerable doubt about whether natural
circulation was working.
One possible course of action at that time would
have been to run the reactor coolant pumps in an
attempt to force cooling flow through the core,
disregarding possible pump damage resulting froml ow reactor coolant system pressure and steam
content. A natural companion to this course would
be to increase the high-pressure injection flow toraise pressure and lessen the amount of steam.
This would enhance reactor coolant pump effectiveness and lessen the likelihood of pump damage.
Another possible course of action would havebeen to increase the high-pressure injection flow
and raise the reactor coolant system pressure. This
826

ditional concern and thus, might possibly have led tomore vigorous actions to cool the core.
Shortly after the conference call was terminated,further radiation alarms and indications of still higher
l evels were received. These later indications wereclearly startling and led to the declaration of a site
emergency at 6:55 a.m.

step would possibly have condensed steam in thesystem and allowed natural circulation to work or
simply to cover the core with water. The highpressure injection flow could also have been increased in combination with more vigorous venting
and lower reactor coolant system pressure in an attempt to establish a flow of cooling water from thehigh-pressure injection pumps through the core andout the PORV or pressurizer vent valve.

Summation

The failure to grasp an understanding of the true
plant conditions during the conference call can be
ascribed to the following factors. The first factor
was failure to understand or pursue known
thefailureeither toi nformation-primarily,
comprehend the implications of the low reactor
coolant system pressure or to find a good explanation for why it existed. Apparently there was a lackof skepticism or a lack of willingness to believe theworst, i.e., that the plant might be in very serious
trouble, the control room operators might have gonecompletely astray, and that a crisis existed with acritical need to get to the bottom of things andcorrect the situation. This is, of course, a natural
human reaction in many circumstances, but training
could foster a more skeptical approach to plant
operating decisions. (Other examples occurred during the day. For example, when Arnold learned of
the containment dome monitor reading he believedthat it was due to moisture affecting the instrument
rather than extremely high radiation levels.)
The second factor was the isolation of Kunderfrom the control room and his lack of awareness ofadditional data that more clearly and forcefully indicated serious problems. For example, Kunder was
unaware of the hot-leg temperature reading thatrose during the call or of the radiation readings that
became truly alarming shortly after the call ended.
The third factor was the nature of the reports
from the control room, for example, the incomplete
information on PORV block valve closure.

Pilot-Operated Relief Valve Leakage

During the conference call Rogers asked about
the status of the PORV block valve. His concern
was to ensure that the discharge of reactor coolant,
which was known from the blown rupture disc, hadbeen stopped. The response, which Kunder obtained from unidentified control room personnel, was-35
simply that the PORV block valve was shut.
Mehler, who directed shutting the block valve, did
not recall any awareness of the conference call or
the question. A more complete report about the
PORV (that it had remained open for more than 2hours) might have significantly changed the participants' perception of plant status. Alternately, further questioning might have elicited more comprehensive information.
Knowing that the block valve had only recently
been shut, should have suggested the possibility
that, until recently, the PORV had been open,
releasing reactor coolant inventory. If so, that would
have explained the reactor coolant system pressure, which was known to be anomalously low
without a good explanation. Abundant data wereavailable upon followup questioning to confirm that
the PORV had been open. Had the open state of
the relief valve, which amounts to a small loss-ofcoolant accident, been understood, then the importance of maintaining ample high-pressure injection
flow should have been realized because the specificpurpose of the high-pressure injection system is to
mitigate small loss-of-coolant accidents.

e. Early Response after Declaration of Site
Emergency (7:00a.m. to noon, March 28)

Radiation Levels

Conference call participants did not recall mention of any indications of radiation problems. Prior
to the call, some radiation alarms had been received
i n the reactor building. However, these were alarmsthat triggered at relatively low levels and would nothave been considered abnormal in light of the blown
rupture disc on the reactor coolant drain tank. Duri ng the conference call, additional indications andalarms of somewhat higher levels began to be received as core damage proceeded. If known to theparticipants, these would probably have caused ad-

Operating Organization

As core damage was proceeding during theconference call, radioactive fission products were
escaping from the core into the reactor coolant system. From there they were leaking into the reactor
building and into process piping systems. Miller
was notified at about 6:45 a.m. of the abnormal radiation readings and he left immediately for the site,arriving in the control room at about 7:05 a.m. At
82 7

6:55 a.m., Zewe declared a site emergency basedon readings on area radiation monitors and process
piping radiation monitors.
When Miller arrived he was briefed by Zewe andothers and formed an emergency command teamthat included Ross in charge of plant operations(directing Zewe), Logan in charge of verifying compliance with procedures, and Kunder in charge ofcommunications and technical support. Rogers was
requested to provide technical support and communication with B&W. Other members of the team
were Shovlin, in charge of maintenance, Dubiel incharge of radiological concerns, and Seelinger incharge of Unit 1. Miller declared that these individuals were to be the funnels through which matters intheir respective areas would be discussed. Other
personnel, including Mehler and Zewe, also participated in team meetings from time to time. When
NRC inspectors arrived later in the day, they attended the team meetings, were encouraged to offer any
suggestions they might have, and were asked tostate any problems they might have with proposedcourses of action.
At about the time the emergency management
team was being formed, many additional operators
were available in the control room. Ross stationed
additional operators at the control panels with shift
foremen and shift supervisors backing them up andcoordinating their activities.
We consider reasonable the emergency command team structure that was selected. It had theadvantage of bringing to bear the collective
knowledge of several people. Miller clearly retained
the responsibility for making the decisions, after discussing various options. Miller considered the funneling of communications important because there
was so much happening. He stated that even withthe funneling he had very little time to think.
Presumably, without it, he would have had none.
Similarly, we consider reasonable placing operators on all or most of the control panels in the control room, backed up and coordinated by supervisors. The control room is large and complex withmany control panels. It would be impossible for a
few operators to keep close track of occurrencesat
the many panels during changing conditions. Again,
the abilities of more people were brought to bear bythis approach.
Of course, when a large team is used rather thana small team, a disadvantage in terms of possible
confusion comes along with the advantage of bringing many people's talents to bear. Nevertheless, wehave no criticism of the basic organization chosen.
We do believe, however, that there were
weaknesses in the organization's performance that

contain lessons for future planning of emergency organizations. The emergency command team missed
some important points during the day. For example,
it did not discuss the stuck-open PORV and throttling of high-pressure injection flow, which were thebasic causes of the accident. This awarenesswould have lent more insight to the discussions.
The team did not clearly understand the complete
significance of the hot-leg temperatures. Time wasspent discussing the questionable notion that the
hot-leg temperature detectors might not indicate thecorrect temperature in a steam environment. Core
thermocouple readings were not discussed, but aquestionable theory about the core flood tanks
cooling the core was endorsed by the team.
There was some confusion in the control room.
Early in the day, for example, Miller directed that thehigh-pressure injection system be kept on. The intent of this direction was subverted during the afternoon. Key personnel have expressed different
opinions about whether or not the high-pressure injection system was cross connected, vital information considering the mode of operating this system
i n the afternoon. As Miller was leaving for Harrisburg, he was not aware of the containment pressure
spike, nor were Logan or Kunder aware of it, butothers were aware of it and thought everyone elseknew about it. During Miller's absence, Joseph
Chwastyk, Shift Supervisor, and Ross were pursui ng different strategies to lower the hot-leg temperature.
We believe that part of the problem was weakness in the qualifications of individuals to handle
emergencies. The need for better operator qualifications and for basic consideration of human engineering is clear with respect to individual control
room operators' abilities to diagnose and handle
emergencies. Some individuals involved in the emergency command team were not well prepared totake charge of plant operations during an accident,
nor to diagnose plant conditions with a critical eye,nor to override operators' decisions where appropriate.
Aside from upgrading individual capabilities, we
believe that a preplanned and practiced organization
for directing plant operations during emergencies
would have improved performance. Some confusion can be expected in any emergency of this nature (some is all we found evidence of); however,the performance of the emergency command teamand the existence of some confusion in the control
room suggest a need to organize and plan for conducting plant operations during emergencies. An
essential part of such planning would be to drill, particularly with respect to communications within the828be sure it was safe to turn it off. Miller instructed
Ross to leave the high-pressure injection system onand not secure it without his permission. This decision followed a discussion by the emergency command team, who had initially decided to turn thesystem off. However, Miller then changed his mind
and countermanded the decision within about 5
minutes. It was Miller's intention to allow the system
to function, as it would have automatically, until plantconditions were better understood.
We consider this sound thinking. In general, it isgood operating practice not to defeat safety devices
while the actuating signal is still present or until it isthoroughly understood that the devices are notneeded. It also appears that throughout the day thebetter chance for adequate core cooling lay withhigher injection flow.
Miller did not specify the system alignment to be
used or the minimum flow rate to be maintained.
However, automatic operation would imply about
900 gallons per minute of net injection flow with full
two-pump operation. (The exact flow rates would
vary depending on reactor coolant system pressure.) The minimum automatic system capability
would be about 450 gallons per minute, whichcorresponds to assuming that only one pump runs.
Later in the afternoon, in response to questions
from the control room, B&W recommended maintaining at least 400 gallons per minute. Miller
depended upon the operators to choose theminimum flow to be consistent with this direction.
We have not determined highly accurate values
for high-pressure injection flow rate during the day.
It is apparent, however, that following Miller's instructions, the operators did maintain substantial net
i njection flow, well in excess of 450 gallons per
minute, until the period of plant depressurization
starting at 11:30 a.m. During the depressurization
period, which lasted until 5:30 p.m.,the net injection
20,37
flow was considerably reduced.
The operators had severely throttled highpressure injection flow in the first few hours of theaccident in an attempt to reduce pressurizer level to
its normal operating range. The reasons for throttling the flow during the depressurization period are
not so clear, but some possible contributing factors
are discussed below.

plant organizations, as has been done in the past for
the radiological aspects of emergencies.
Miller has stated that communicating with outsideorganizations placed a significant burden on him intrying to manage the emergency. We agree that
this must have been a burden. He held many telephone briefings for both company and State officials, and there was a 2 1/2-hour absence to brief the
Lieutenant Governor. Miller noticed a tendency foroutside officials to want to speak to someone incharge. He and others have recommended that thisbe considered in future emergency planning by including a designated communicator in the emergency response organization to handle such contacts.
More fundamentally, Miller has stated that communications that have been practiced, work.
Plant Status

Aside from forming the emergency management
team, Miller spent his first half hour or hour concentrating on radiological concerns and the required
notifications of offsite organizations before turning
his attention to plant operations. During this initialperiod, at about 7:24 a.m., he declared a generalemergency based on indicated radiation levels in thereactor building.
When Miller and the emergency management
team turned their attention to plant operation atabout 7:45 a.m., the reactor coolant pumps werestill off and reactor coolant system pressure wasstill fairly low at about 1500 psi. Pressure had increased to about 2100 psi at 7:00 a.m. following
closure of the PORV block valve at 6:20 a.m., and inconnection with the running of one reactor coolant
pump from 6:54 to 7:13 a.m. The hot-leg temperatures were high at about 780° F, the cold-leg temperatures were low at about 300° F. Natural circul ation was not working. The hot legs were vapor
bound. The high-pressure injection pumps were injecting cold water, perhaps at reduced flow. Reactor coolant pressure was being kept low by intermittent venting of the pressurizer into the reactor buildi ng and, perhaps, by reducing high-pressure injection flow. Although it was not known at the time,
subtle changes in several plant variables indicatedthat severe core damage and mechanical disarrangement had occurred by 7:45 a.m.

The pressurizer level was still high- I ntermittent attempts were made during the afternoon to draw abubble in the pressurizer by turning on the pressurizer heaters. Apparently this did result in pressurizer level decreases at times. We do not, however,think the operators were throttling high-pressure in-High-Pressure Injection FlowAn early decision made by Miller at approximately 8:00 a.m., was to allow the high-pressure injection system to continue functioning because notenough was understood about plant conditions to82 9jection flow at this time either to reduce pressurizer
l evel or to draw a bubble in the pressurizer.
As discussed above, Miller had not been specificabout. what flow rate should be maintained. Zeweand others wanted to use the minimum flow ratethat would still assure core cooling. Less flow
would reduce the frequency of opening and closing
the PORV block valve to maintain reactor coolant
system pressure. The operators had been concerned about possible failure of the block valve
under frequent cycling during the previous highpressure operating mode. In addition, the goal duri ng this period was to reduce reactor coolant system pressure, which the reduction of injection flow
could help, and which might also have contributed
to a desire to use the minimum adequate flow rate.
At the beginning of the depressurization period, theoperators recalled first attempting to throttle highpressure injection flow to about 225 gallons per
minute, but since it was difficult to throttle to such alow value, they maintained flow at about 340 gallons
per minute. 38
I n their testimony, the operators apparently concentrated on indicated high-pressure injection system flow rather than net injection flow (which would
be approximately the high-pressure i njection flow
minus letdown flow). For example, Zewe and others
recalled the total indicated high-pressure injection
flow as being in the neighborhood of 340 gallons
per minute during the depressurization period.
This figure appears to be close to the minimum automatic system capability (about 450 gallons per
minute, or the B&W recommendation of at least 400
gallons per minute). On the other hand, borated
water storage tank (BWST) level readings at 1:15
and 5:20 p.m. indicate, at most, a net injection rateof about 150 gallons per minute during this 4-hour
period.

which should be subtracted to obtain net injection
flow. If so, it can be said on their behalf that the letdown water was cooled prior to recycling into thereactor coolant system and thus, letdown flow could
be expected to contribute in some sense to coreheat removal. This would have been true if the system was full of water and circulating the water
through the core. However, the system was not fulland the actual needs were either to replace lost
reactor coolant inventory; to establish a cooling water flowpath from the high-pressure injection pumps
through the core and out the pressurizer safety, relief, and vent valves; or to do both. For these purposes, it was net injection flow that was important.
The net injection flow of about 150 gallons per
minute was, for several hours, much less than the1000 gallons per minute that the high-pressure injection system could provide.
There is the possibility of an operating error resulting in inadvertent cutbacks in injection flow- Attempts were being made during the afternoon tobias the high-pressure i njection flow to the "C" injection path (that is, through valve MU-V-16C). One
way to accomplish this would be to close valves
MU-V-16A and "B" in the other two injection paths.
If this were done, leaving only the "A" pump running(as was the case most of the afternoon), it would
cut off nearly all flow. (This condition would occur
provided valve MU-V-17 was in an automatic modeand closed because of a high pressurizer level signal, and provided the manual cross connect valves
were shut as they should have been.) We do notbelieve that this potential error resulted in severely
throttled high-pressure injection flow, at least not forlong periods of time. Ross testified that when attempts were made to bias flow to the "C" leg, the"C" pump was started, which would then provide
flow via valve MU-V-16C. Furthermore, if the flow
were inadvertently reduced by such an error, thereduction would have been indicated on the highpressure injection system flow meters at the verytime the operators were adjusting the flow, andtherefore the operators must have been reading theflow meters.

The operators were operating the letdown systemthroughout the day- This water came from thereactor coolant system and was recycled back into
the system through high-pressure injection pumps.
(Such flow would not have existed in an automatic
operation.) If the letdown system flow was near its
maximum flow rate of about 160 gallons per minute,that could eliminate most of the discrepancy
between the estimated net injection rate of 150 gallons per minute and the operator's recollections ofabout 340 gallons per minute of high-pressure injection system flow.
Thus it is possible that the operators, seeking theminimum adequate flow, maintained a high-pressure
i njection system flow rate in the neighborhood of
340 gallons per minute, neglecting the letdown flow,

Other Early Actions

One of the emergency management team's firstdecisions was to restart a reactor coolant pump toestablish forced cooling water flow through thecore. One pump was started at 8:08 a.m., but was
tripped by the operators in less than a minute because of low current and low flow, indicating thatthe reactor coolant loop was vapor bound. It was
83 0considered that continuing to run the pump in a vapor bound loop would not pump water through thecore and might damage the pump, possibly causing
a seal failure, which would create a small loss-ofcoolant accident.
Early in the day the team established its priorities
as (1) protection of the public, (2) covering and cooli ng the core, and (3) protection of plant personnel
and equipment. Protecting plant personnel andequipment was actually second but cooling the core
was the way to accomplish this. 39 We consider
these reasonable, even in retrospect.
Miller requested readings from the incore thermocouples; instruments not intended or qualified for
postaccident service of this sort. However, Miller
believed they might give useful information aboutcore cooling and perhaps confirm that natural circulation was working. Several readings were taken
and reported to Miller by Ivan Porter. The readings
varied from 80° to 2620° F. Because these thermocouples are all located in the same horizontal planea few inches above the active core region, thisrange of temperatures, all at the same time, did notappear real. For this reason, and because the qualifications of the thermocouple for these conditions
were doubted, Miller and Porter did not consider thereadings reliable. Miller later told us they had to beconsidered reliable in the sense of indicating thepossibility of high temperatures in the core, but notin the sense of indicating what the actual temperatures were. He did not recall discussing the readings with the emergency command team; however,
he did later report on the general nature of thereadings to Herbein with the caveat that they were
probably not reliable. Porter also felt that the readi ngs were unreliable and later told us that the hotl eg temperatures were a better and more reliable indication of core cooling conditions.
Many other thermocouple temperature readings
were taken by the instrument technicians shortly
thereafter, and were left in a book in the control
room when unnecessary personnel were evacuatedfrom the site. However, the book was not read byPorter or Miller. Further details on the handling ofthese thermocouple readings are provided later inthis section of the report.
Decision to Increase Pressure

At approximately 9:15 a.m., Miller decided to increase reactor coolant system pressure. Pressure
was raised to about 2100 psi by closing the PORV
block valve to stop venting of the pressurizer. Pressure was then maintained at this level by intermittently (and frequently) opening the PORV block
83 1

valve to vent the pressurizer. It was hoped that thishigher pressure would collapse and condense the40,41
steam bubbles in the reactor coolant system.
Had this strategy been successful, the system
would have refilled with water, and natural circulation or the reactor coolant pump operation could
have provided cooling water flow through the core.
Aside from that, at least some consideration wasgiven to the fact that this action, by itself, could establish a core cooling flow path from the highpressure injection pumps through the core, out the
PORV, and into the reactor building. 42 I n either
event, we believe the best chance for adequate
core cooling lay with high-pressure injection flow. It
appears that the operators did indeed maintain substantial injection flow. For example, the average net
i njection flow between about 8:30 and 10:30 a.m. is
estimated to have been 640 gallons per minute. 20
The strategy did not appear to be successful incondensing the steam bubbles because the hot-leg
temperatures remained high, even though reactor
coolant system pressure was maintained at about2100 psi for more than 1 1/2 hours. In addition, no
significant amount of heat was being transferred tothe steam generators. The lack of success was apparent; the reasons were not.
We consider this strategy to have been reasonable. A similar strategy did work later in the afternoon, after more gas had been vented from thereactor coolant system. The net injection flow at
this time could have been somewhat higher, whichmight have given the strategy a somewhat betterchance for success. It would have required morevigorous venting, possibly eliminating more hydrogen from the reactor coolant system and providing
greater cooling water flow through the core. However, the net injection flow rate, if not at the maximum, does appear to have been substantial andwell in excess of the minimum one pump design
43
capabilities of the high-pressure injection system.
It is possible the reactor coolant system waspartly refilled with water in the cold legs (where thereactor coolant pumps are located) if not in the topsof the hot legs (where the hot-leg temperaturedetectors are located). If so, it might have beenpossible during this period at high pressure to establish effective core cooling by running a reactor
coolant pump and obtaining partial flow despite thegas content. This had been done earlier in the daywith considerable steam vapor and would be done
again later that afternoon although considerable hydrogen remained in the system. No attempt wasmade to run a pump at this time. The general feeli ng was that, since it had been tried earlier without
success, it would be futile to try again until the va-

por binding in the reactor coolant loops had been
eliminated. We have no criticism of this reasoning
since there may have been too much gas in thesystem at that time for successful reactor coolant
pump operation.
As indicated by the hot-leg temperature, the strategy was not successful in completely freeing thesystem of gas, at least in the time allowed it, because the core was very hot; producing steam, hydrogen, or both, from water contacting the hot portions. This would tend to keep the system full ofgas and cause water flow to bypass the hot portions of the core on its way to being vented from thepressurizer. To the extent that the gas was hydrogen, it could not be condensed; nor could any
steam that remained hotter than about 642° F be
condensed at the 2100 psi pressure.
Even if the operating staff had realized that thecore was badly damaged and that there was considerable noncondensible gas in the system, they
did not have a cooling system that had been specifically designed to work under those circumstances.
Emergency core cooling systems are, instead,designed to actuate rapidly and automatically toprevent such overheating, damage, and hydrogengeneration. (We are not saying these systems willor will not cool cores damaged to various degrees.
Rather, since they weren't designed to do so, we
don't know to what extent they can be effective.)
No prior consideration was given to which strategies
would provide the best chance of cooling a damaged core. Thus, the operating staff would have
had to improvise on the spot even if the nature ofcore damage had been correctly understood.

Furthermore, aside from damaged core consideration, there was no specific procedure or system design for cooling even an intact core underthese circumstances (reactor coolant pumps notavailable and natural circulation blocked). Here, thedesign philosophy was similar. If the reactor coolant
pumps became unavailable, natural circulation was
designed to work and cool the core, preventing
steam formation and the consequent blockage ofnatural circulation.
Decision to Depressurize
At about 11:00 a.m., it was decided to depressurize the reactor coolant system. The pressurizer
was vented into the reactor building, reducing reactor coolant system pressure to about 500 psi. Intermittent venting continued to maintain a low pressure until about 5:30 p.m. Throttled high-pressure
i njection flow was maintained.

A primary reason for changing the strategy was
the apparent lack of success in filling the reactor
coolant system with the previous high pressure
strategy, since the hot-leg temperatures had
remained high. There was also concern that injection flow had been bypassing the core on its way to
the PORV (a concern that continued throughout theday) and the related concern that the core might be
uncovered. Finally, there was concern that the
PORV block valve might fail under the frequent cycling in the previous operating mode.
Several accomplishments were expected fromthe new strategy. The most frequently cited was
the expectation that the core flood tanks would aid
i n core cooling. The two core flood tanks are water
accumulators maintained at 600 psi by compressed
nitrogen volume on top of the water. They are connected to safety injection nozzles in the reactor
vessel above the core. In the event of a large lossof-coolant accident, the tanks are designed to rapidly inject cold water through check valves when
the reactor coolant system pressure drops suddenly below 600 psi.
It was expected, therefore, that if the core was
not covered, the flood tanks would inject water
when reactor coolant system pressure dropped
below 600 psi. On the other hand, if the core wascovered, the lack of injection was expected todemonstrate that this was the case. This theory
sounds reasonable on the surface, but it was incorrect.
When the system pressure is dropped to 500 psi
by venting, only about 8% of the core flood tank water can be injected through the existing loop seal
piping arrangement-enough to drop the nitrogen
bubble pressure to 500 psi. If another piping configuration had been used whereby piping ran continuously downward from the core flood tank to thesafety injection nozzles rather than through a loop
seal, all the water could have flowed into the reactor
vessel with gas bubbling up into the core flood tank.
However, that configuration was not used in thisplant. (The loop seal would not adversely affect theintended function of the tank, which is injecting water during a large pipe break accident. It only became significant in these particular circumstances.)
When a drop of only about a foot in tank level
was noticed it was taken to be confirmation that thecore was covered. On the contrary, the drop
corresponded approximately to the amount of water
discharge that could be expected under these conditions.
Later, after the initial blowdown to 500 psi, thepressure rose a bit above 500 psi and the operators vented more vigorously trying to reduce the
83 2

tent; the existing system vent capacity; and the hot,damaged core. The core was apparently producing
enough steam from water that contacted it to maintain system pressure above 440 psi, even when all
the available vent valves were open. (Alternately,
the water may have been converted to hydrogen in
the hot core, but the volume increase would be
about the same in either case.)
The third expectation-to establish cooling waterflow from the high-pressure injection point to thepressurizer vent points-was reasonable. To a degree, however, it was inconsistent with the otheraims. Ample high-pressure injection flow would givethe best chance for success with this method,which is inconsistent with the throttling of highpressure injection flow that occurred.
This depressurization may have contributed tothe success of a later high pressure strategy byventing additional hydrogen from the system. Thiswas done by the initial blowdown and it was notnecessary to continue it for 6 hours.

pressure further. (The PORV was open for morethan an hour, with the pressurizer vent valve also
open during the last half hour). The pressure
dropped only to 440 psi, probably being held up by
gas heating, steam generation in the hot core, orboth. After that they vented only intermittently, allowing the pressure to drift up to about 650 psi at
5:30 p.m.
A second expectation was that, if pressure could
be reduced much below 400 psi, the decay heat removal system could be run. This low pressure system is normally used for core cooling after the reactor coolant system has been cooled and depressuri zed. It was not used that day because the pressure did not get low enough.
Another expectation held by several key people
was that the pressurizer venting, in combination withhigh-pressure injection flow, would create a coolingwater flow path through the core. This was a reasonable expectation. The hot, damaged core would
tend to force more flow to bypass it and go throughother pathways on the way to the PORV than would
an intact core. As with the previous high pressure
strategy, the best chance for adequate cooling by
this method would have been with maximum injection flow. Ample high-pressure injection flow would
tend to keep the pressure up, competing against theaims of the other two methods. In any event, injection flow was severely throttled.
Finally, this strategy, which addressed concerns
about failure of the valve from frequent cycling, did
reduce the frequency of cycling the PORV block
valve.
I n evaluating the depressurization decision, we
recognize that the emergency command team wasfaced with an apparent lack of success in ensuringcore cooling through natural circulation and therefore had a need to do something different. The
team was also handicapped by the lack of an effective system or procedure for meeting these circumstances. However, because the decision todepressurize was heavily based on the incorrect
theory that the core flood tanks would ensure corecooling if the pressure were lowered, we cannot
consider it a reasonable decision. Apparently, various people involved either did not know of the loop
seal piping or did not understand what its effectwould be, or, if these factors were understood, did
not consider how little water would be injected by
the reduction of pressure.
The second expectation-reducing pressure
enough to allow operation of the decay heat removal system-was not unreasonable in that it might
have worked if the system had been cool and solid.
However, it was not feasible with the large gas con-f. Offsite Activities
Met Ed Headquarters Activity

Richard Klingaman of the Generation Division at
Met Ed Headquarters in Reading, Pa., was informedof the site emergency at about 7:00 a.m. He andGeorge Troffer, also of the Generation Division, informed numerous company staff and management
personnel, including Creitz and Arnold.
For the rest of the day (March 28) and during thefollowing day (March 29), Generation Division personnel in Reading primarily performed communication functions. They received several reports fromthe plant site and reported the status to company
staff and management personnel. Occasionally,messages were relayed from organizations thatwere having difficulty contacting the control room.
Many calls offering outside assistance were received.
During the evenings of March 28 and March 29,
Generation Division personnel in Reading assistedcompany public information personnel in answering
public inquiries about plant status. The public inquiries were primarily from the press and from concerned citizens.
The Generation Division personnel in Reading did
not influence decisions on plant operations for avariety of reasons. Klingaman told us that the reports from the plant summarized the plant status
and outlined the planned actions rather than providi ng data upon which an independent diagnosis could833

be made. Miller said that these reports were intended to convey information that could be passed
on to others rather than to obtain assistance or advice. Generally, the planned actions appeared reasonable at the time and thus, did not impel the Generation Division personnel to question them. Finally,by 11:40 a.m., Herbein, who was the head of theGeneration Division, was at the plant.

Herbein did not learn of the containment pressure
spike that occurred at 1:50 p.m. until it became general knowledge on Friday morning. 47 He was probably unaware on Wednesday that the PORV had
failed to close. This can be assumed since Miller,
his source of information, was not aware of it, anduntil Thursday afternoon or later Herbein was
unaware that high-pressure injection flow had been
48,4s
severely cut back.
During this first period at the Observation Center,
Herbein made two significant decisions that were, in
essence, contrary to the advice and recommendations of the plant staff: the decision to stopdischarging steam to the atmosphere and the decision to take Miller and Kunder to the briefing of the
Lieutenant Governor. These decisions are discussed in the following sections.

Herbein Activities

Throughout the day, Miller and Herbein had
several discussions about plant operations. Their
testimony generally includes few details concerning
those discussions where Herbein concurred with
Miller. More information is available concerning thei ssues where Herbein made a decision contrary toMiller's recommendation.
At about 9:30 a.m., Herbein was told by Creitz to
go to the site. He left Philadelphia by helicopter at
about 11:00 a.m. and arrived at the Observation
Center at about 11:40 a.m. He discussed the emergency by telephone with Miller and remained at theObservation Center until about 1:15 p.m., when hemet the press on the lawn outside. After this press
conference, at about 2:00 p.m., Herbein left for abriefing of Lt. Gov. Scranton in Harrisburg with Miller and Kunder.
Since about 10:00 a.m., the plant staff (emergency management team) had been maintaining a highreactor coolant system pressure (between 2000
and 2100 psig) by injecting water with the highpressure injection system, and venting from thepressurizer as necessary to maintain pressure
within this band. At about the time Herbein arrived
at the center, the decision was made to depressuri ze the reactor coolant system to enable the coreflood tanks to inject water and possibly to allow
operation of the decay heat removal system. Herbein believed he was informed of this decision andconcurred. This basic mode of operation was tocontinue until Herbein and Miller returned from the
Lieutenant Governor's office at about 4:30 p.m.
In the first telephone conversation at the Observation Center, Herbein recalled being told that theradiation readings in the reactor building had required the declaration of a general emergency andhe was briefed on the status of the plant. He recalled being under the impression that some fuelhad failed, the core was covered, natural circulation
was working, safety systems were working, and44theradiation levels around the plant were very low.
Herbein may have been told of steam bubbles in
the hot legs. 45 He probably learned of the hot-leg
temperatures and the initial set of core thermocouple readings sometime later in the day. 46

g. Decision to Stop Discharging Steam (1:15
p.m., March 28)
Background

Herbein's decision to stop discharging steam tothe atmosphere warrants discussion. This action
appears at first glance to be questionable because it
deprived the operators of what would normally be
the heat sink for core cooling when the main condenser is not available. However, upon closer examination the decision does not appear unreasonable.
The direction to stop discharging steam to the atmosphere was given at about 1:15 p.m. Since 11:40
a.m., the operators had been following a strategy ofventing from the pressurizer to lower reactor
coolant system pressure. In connection with highpressure injection flow it was believed that thisventing would provide cooling water flow throughthe core. It was also hoped that the lower pressure
would allow the core flood tanks to inject water toprovide confirmation of core coverage and possibly
allow operation of the decay heat removal system.
I n addition, at that time the operators weredischarging steam from the secondary side of thesteam generators to the atmosphere, hoping tofurther cool the steam generators and establish natural circulation flow on the primary side, which isthe normal means of providing core cooling flow
under these circumstances.
Herbein had heard of releases of radioactive materials off site, which he wanted to stop; and of generator tube leakage, which indicated that the steam
discharged to the atmosphere might be a source ofthe release. Miller at first objected to stopping thedischarge on the grounds that it would deny him the834

heat sink for core cooling. He was also convincedthat this steam was not the source of off site
releases. Eventually, Miller gave in and stopped thedischarge.

vacuum had been lost. Discharging steam to thecondenser without vacuum would overpressurize it.
As it later turned out, the operators were left withouta steam discharge path for several hours until condenser vacuum had been reestablished.
The methods discussed above are the only accepted, analyzed, and qualified methods for corecooling, for normal operations, and-prior to cooldown and depressurization of the reactor coolant
system-for conditions permitting decay heat removal system operation. Thus, this decision appears
to deny the operators the only accepted method ofcore cooling available-feeding and discharging
steam from the secondary side of the steam generators, to the maximum extent possible to establish
natural circulation flow on the primary side. Furthermore, this was done to stop the discharge of steamthat did not contain significant quantities of radioactivity.
Another apparent concern was the impression
expressed by some plant staff personnel, that thedecision resulted largely from heavy pressure by
the State Government to eliminate the visible steam
plume that resulted from dumping steam to the atmosphere.
If true, that would represent a
dangerous precedent, but we found no evidence
that this was the case.

Apparent Concern

We have evaluated this decision primarily because it would appear, at first glance, to be questionable; eliminating what is normally the heat sinkfor core cooling.
Following a reactor shutdown without a loss-ofcoolant accident and before the reactor coolant
system has been cooled and depressurized to allow
operation of the decay heat removal system, decay
heat is removed from the core by running the reactor coolant pumps to force reactor cooling water
through the core. If the reactor coolant pumps are
not available, as was the case here, natural circulation flow i n the reactor coolant system is utilized. In
either case, the heat is transferred to the steam
generators and is in turn removed by discharging
steam from the secondary side of the steam generators to the main condenser. If the main condenser is not available, as was also the case here,
the heat is removed by discharging this steam tothe atmosphere through the atmospheric dump
valves.
Natural circulation in the reactor coolant system
consists of reactor cooling water being heated in
the core, rising to the hot-leg piping, and flowing to
the steam generator. There it is cooled, sinks to thecold-leg piping, and flows back to the core. Whenattempting to establish natural circulation, as theoperators were doing here, it is important to cool
the steam generators by adding feedwater to thesecondary side and by discharging steam from thesame side. This cooling, along with heating in thecore, provides the thermal driving head for natural
circulation flow on the primary side (the reactor
coolant system).
If natural circulation flow has been deficient (orthe reactor coolant system pressure has been low)
allowing the generation of steam bubbles, thosesteam bubbles tend to block natural circulation flow.
This is the case that existed in the plant. Amongother things, in this case one would want to cooland fill the secondary side of the steam generator
as much as possible by injecting feedwater anddischarging steam, hoping to condense enoughsteam on the primary side to reestablish natural circulation flow. This is what the plant staff wanted todo.
At the time it was decided to stop discharging
steam to the atmosphere the main condenser was
unavailable for dumping steam because condenser

Actual Core Cooling Situation

When the decision to stop discharging steam
was made, plant conditions were highly abnormal
and nothing was lost by securing steam discharge.
At that time, both steam generators were fairly fulland cold and they remained that way throughout theafternoon. This indicates little heat transfer from theprimary to the secondary sides because the primarysides of the steam generators were full of steam
and hydrogen. This mixture was indeed blocking
natural circulation flow. The substantial amounts ofnoncondensible hydrogen (unknown at the time)
could not be condensed to help unblock natural circulation flow. Also, since the steam generators
remained full and cold anyway, additional steaming
to cool them further would have produced very little
additional thermal driving head to condense steam
and promote natural circulation.
The alternate method of core cooling that Herbein discussed with Miller was high-pressure injection flow i nto the reactor coolant system combinedwith venting from the pressurizer into the containment, hopefully establishing a cooling water flow
path across the core. This is, in effect, creating asmall LOCA so that the high-pressure injection system can cool the core. This method had not been
analyzed, reviewed, accepted, qualified by testing,835

nor included in procedures as had the other, accepted methods discussed above. However, it waswell known as a possible backup method in theevent that steam generator cooling should fail. The
alternate method was at least as reasonable as theaccepted method-natural circulation-which was
not working and could not be made to work bydischarging steam.
Herbein recalled believing at the time of the decision that natural circulation was not working very
effectively to cool the core because of steam bindi ng in the hot legs. 50

Summation

On balance, we do not believe the decision tostop discharging steam was unreasonable.
h. Key Personnel Leave for Harrisburg (2:00
p.m., March 28)
Background

Another action warranting discussion was
Herbein's decision to go to Harrisburg to brief Lt.
Gov. Scranton, taking key personnel with him. To
the extent that it involved removing Miller andKunder from the plant, the action was, in essence,
contrary to Miller's initial recommendation. Miller
eventually did acquiesce, and along with Kunder andHerbein left to brief the Lieutenant Governor in Harrisburg shortly after 2:00 p.m. They returned to thesite about 4:30 p.m.
The request for a briefing had come earlier from
Lt. Gov. Scranton to Creitz. Creitz decided that
Herbein would be the appropriate individual, and told
Herbein to attend the briefing.
To our knowledge, the Lieutenant Governor did
not have reason to think that he should not be
briefed because the company personnel were moreurgently needed at the plant to set up core cooling.
The Met Ed public statements and Miller's telephonebriefing of the Lieutenant Governor had not indicated such a situation. In any event, we are notevaluating Lieutenant Governor Scranton's decision
to request a briefing because we believe theresponsibility for recognizing the plant situation and,if necessary, either refusing the request or sending
someone else rested with the company.
The action was questionable because Herbein,
Miller, and Kunder absented themselves from theplant for about 2 1/2 hours at a time when the core
had been badly damaged and was not effectively
cooled. Moreover, there was confusion, an accurate diagnosis of the true situation was lacking, anda hydrogen burn had just occurred. On the other
hand, not all of this was understood at the time,
numerous qualified people were available to run thepl ant, and communications were maintained during
their absence.

Other Factors

Herbein had learned about radiation levels above
normal background values, which indicated someoffsite releases, and believed that the steam
discharge could be the source. He suspected thisbecause he was aware that a primary to secondary
l eak had been identified earlier in the day. 51 Miller,
on the other hand, was more convinced that thesteam discharge was not
the source of the releases
52
of radioactive materials.
Upon securing the discharge to atmosphere,. one
would expect the operators to establish condenser
vacuum and dump steam to the condenser. Any radioactive materials released from the condenser
would be processed through charcoal adsorber units, removing most of the material prior to releases
to the atmosphere. This would then provide asteam discharge path with far lower release rates incase the steam was the source of the releases ofradioactive materials. The operators set out to do
this but, as it turned out, they ran into problems andit took several hours to establish this discharge
path.
Herbein had been made aware by someone that
there was pressure from the State Government tostop discharging steam. He had no conversations
himself with State Government personnel. Believingthat this was a factor to be considered, Herbein discussed it with Miller but made the decision primarily
i n an 53
attempt to stop the releases of radioactive material.
Although many people in the control room had
the same impression of State pressure to stopdischarging steam, we did not run across any direct
knowledge of where this impression originated.
One NRC inspector did recall urging such action.
However, it doesn't really matter where this impression originated. As Herbein stated, if the State had
a concern, it would have been the same concernthat motivated him as hevarious54 balanced
factors-to stop the releases.

Plant Status

At the time that Herbein, Miller, and Kunder left,
the operators had been following a strategy of venti ng from the pressurizer to lower the reactor coolant
system pressure. It was intended that this would
provide cooling water flow through the core, in con83 6

There were numerous people in the control room,and they had to wear respirators at various times
during the day. These factors alone tended tocreate confusion.
It i s difficult to conclude, from interviews anddepositions, that there was a coherent plan for corecooling in effect during the absence of the key personnel, other than to maintain the status quo. For
example, Chwastyk, who was in charge of the control room, was attempting to draw a bubble in thepressurizer and attributed the reactor coolant temperature responses to these actions. Chwastyk's
action was unknown to Ross, who was in charge ofoverall operation and a member of the emergency
management team. Ross, meanwhile, believed that
attempts to bias high-pressure injection flow to the"C" leg were the significant actions and attributed
the temperature response to this. Logan andRogers do not recall any plan other than to maintainthe status quo.
Chwastyk recalls diagnosing the containmentpressure spike as an explosion associated withventing the pressurizer, and of so informing Miller
prior to his departure. Ross, while not thinking of
the pressure spike as an explosion, did realize thatthe pressure spike had occurred and the containment spray pumps had started. He discussed thenoise with Miller and believed that Miller also knewthat the pressure spike had occurred and the containment spray pumps had started.
Miller, however, recalled only asking about thenoise and being told that it was probably caused bya ventilation damper. He did not recall being awareof the pressure spike or the containment spraypump operation, much less of the diagnosis of an
explosion. Nor did Herbein recall Miller informing
him of these occurrences. These events would all
have taken place shortly before Miller left for Harrisburg. If the confusion and rush of leaving was areason why some of this information did not reachMiller, as it could have been, then leaving was certainly a drawback.

junction with high-pressure injection flow. In addition, it was hoped that the lower pressure would all ow the core flood tanks to inject water providing
confirmation of core coverage and, possibly, allow
operation of the decay heat removal system.
A hydrogen burn occurred in the reactor building
at 1:50 p.m., shortly before Miller's departure. Thisburn resulted in a 28-psi pressure spike and starting of the containment spray pumps. Miller recalled
hearing a thud at this time, but not being aware of
the pressure spike or of the containment spraypumps running.
Prior to leaving, Miller noticed a small drop incore flood tank levels and some change in reactor
coolant temperature, which he considered to be indications of success for the core cooling strategy.
Later, as the lowered hot-leg and increased cold-leg
temperature indications became more pronounced,
they were attributed by Ross to biasing injection
flow to the "C" leg, and by Chwastyk to drawing abubble in the pressurizer.
Reasons for Leaving and Precautions Taken

Herbein was under the impression that firsthandknowledge had been specifically requested by Lt.
Gov. Scranton, and he felt it was necessary to takesomeone from the plant staff with him. 55 Miller initially objected but then directed Kunder to gather
data on plant conditions and to accompany himself
and Herbein to Harrisburg. 56
Miller and Herbein stated that there werenumerous qualified people available in the plant atthat time. Logan was left in charge with instructions
to maintain the status quo.
The emergency
management team had been set up and had beenfunctioning for several hours. NRC and B&W
representatives were on site.
Miller took a telephone beeper so he could be
paged, if necessary, during the trip. If needed, hewould be only about 20 minutes away. Once at the
Lieutenant Governor's Office, telephone contact
with the control room was established and maintained.

Possible Consequences

At about 2:30 p.m., Arnold called the control
room to express concerns as to whether the primary system was solid. He spoke to Rogers who
said that the conclusion of the emergency management team was that the core had always been
covered.
The decision to repressurize and then to run areactor coolant pump was made by Herbein, in consultation with Arnold, at about 4:30 p.m. upon his
return from Harrisburg. At best, if Herbein had not

Drawbacks of Decision

We know now that the basic problem with key
personnel leaving at that time was that things were
confused, the true situation in the plant had not yet
been diagnosed, and effective corrective actions
had not yet been prescribed. Thus, if these key
people had stayed, it might have helped to alleviate
confusion or to arrive at effective corrective action
sooner.
83 7

gone to brief the Lieutenant Governor, he might
have brought about this decision sooner. For example, if he had discussed matters with Arnold at
about 2:30 p.m., Herbein might have reached thedecision at that time. Because massive core damage had already occurred by the time Herbein left,
however, it does not appear that reaching this decision 1 or 2 hours earlier would have materially altered the physical course of the accident.
One can speculate that, had Miller stayed, hemight have recognized the containment pressure
spike, and either understood its significance or informed others who might have comprehended its
significance. If the significance of this event had
been generally conceived on Wednesday, one canfurther speculate that in the next few days theoverall situation would have been safer because (1)actions to handle the hydrogen bubble would havebeen taken sooner, shortening the time that thispresented a potential threat to continued core cooli ng and (2) contingency planning would have beeni mplemented faster, reducing the risk involved.
Summation

Although it did not materially worsen the physicalcourse of the accident, on the basis of what we now
know, the decision to leave the plant does not appear sound because the true plant situation had notbeen diagnosed and effective corrective action had
not been prescribed. On balance, we believe that it
was poor judgment for the two top management
personnel at the site to depart when there was nooverwhelming evidence that the plant was being
cooled down effectively. Ample evidence of uncertainty and doubt apparently also exist in the mindsof others in the control room. The leader's place isat the source of the problem until it is completely
resolved. The judgment to leave may be anothercase of not wanting to believe bad news. Full
preparation and planning, particularly of communications with appropriate offsite officials, could haveavoided the accident's severity.

tion, the GPUSC personnel became very concerned
as they found out more about the plant status.
Eventually, at about 4:30 p.m., they recommended
to Herbein to repressurize the plant. Herbein
agreed and directed that it be done. This action,
along with the subsequent starting of a reactor
coolant pump, resulted in a stable core coolingmode that was maintained for about 3 weeks.
Chronology

Arnold was notified of the emergency in a brief
telephone call from George Troffer, Met Ed Manager
of Quality Assurance, at about 7:59 a.m. He wastold the following: that there had been a turbine anda reactor trip, there appeared to be a primary to
secondary leak in the B steam generator, there
were increased radiation levels in the reactor buildi ng and a site emergency had been declared. 57 Arnold was under the impression that the site emergency had been declared because of the steam
generator tube leak, however, he was unaware of
the very high reactor building dome monitor radiation reading and the declaration of a general emergency. At the time, Arnold did not suspect any continuing problem with core cooling. 58
Within about /2 hour Arnold discussed the plant
trip with Creitz and Herbein and decided to send ateam of five engineers to the site. The purpose of ateam of engineers going to the site was to review
the plant history and initiate the investigations that
normally follow such a plant trip before returning theplant to power; however, they were not to assist in
bringing the plant to a safe condition. 59 it was apparent that the information would be better obtainedat the site than by telephone.
The team of five engineers left, and individual
GPUSC members began arriving at the site at 2:00
p.m. Upon arrival, they began to gather data on
what had happened.

Meanwhile, Arnold probably learned that thereactor coolant pumps were off during his first60
conversation with Herbein, shortly after 8:00 a.m.
Between approximately 10:00 and 10:30 a.m., Arnold
and his staff discussed the situation with personnel
i n the control room. At this time, they learned of thevery high containment dome radiation monitor reading. Arnold recalled suspecting there was a moisture problem with the instrument, causing the highreading. He retained this impression for days. 61.62
Wilson, on the other hand, did not recall discussions
during the day where this reading was dismissed as
erroneous or not meaningful.
At about this time, Arnold began to suspect thatsome fuel damage had occurred. He was informed

I. General Public Utilities Service Corporation(GPUSC) Activities
Background

Robert Arnold at GPUSC, the company's primarypool of engineering expertise, was informed of theplant trip at 7:59 a.m. Arnold subsequently held
several discussions with his staff and by telephonewith company personnel at the plant. Although
GPUSC had no formal responsibility for plant opera838

I n addition, B&W headquarters probably hadsome influence on the thinking at GPUSC. B&W
personnel had found out that high-pressure injection
flow was throttled and the hot-leg temperatures
were high. They were trying to get their recommendation to increase the injection flow to the control
room. Deddens of B&W recalled calling Arnold at
about 2:00 p.m. and again at about 4:30 p.m. withthis recommendation. Although he did not disputethese conversations, Arnold did not recall them.

by Troffer at about 11:45 a.m. that offsite releases
63
By about 2:00 p.m. Arnold's
had been detected.
staff told him of their concern that the reactor
coolant system was not filled; that is, there was asteam bubble in the system outside the pressurizer,
implying that the core was uncovered or was not
being cooled effectively. Arnold recalled that thiswas based on data his staff had obtained independently from the plant rather than through himself.
In a telephone conversation shortly after 2:00
p.m., Arnold expressed concerns to Rogers in thecontrol room about steam in the reactor coolant
system, implying an uncovered core. Rogers
responded with the plant staff's conclusion that thecore was covered. Arnold did not believe that this64
At the time of this call, Miller
was unreasonable.
and Herbein were briefing Lt. Gov. Scranton in Harrisburg.
After the call, Arnold's staff further discussed
their concerns with him. In particular, they emphasized concern that steam bubbles in the system
may not have been collapsed. These conversations
i ncreased Arnold's concern and he decided to press
more forcefully for corrective action. Arnold later
spoke with Herbein and emphasized the corrective
action recommended by his staff. Although Arnold
was now very concerned about steam in the system
and a possible uncovered core, it did not cross his
mind that a metal-water
reaction had occurred or
65
was proceeding.

Summation

GPUSC, along with Herbein, played a vital role inestablishing a stable core cooling mode on theafternoon of March 28. Like Herbein, the GPUSC
personnel had no specific assigned responsibilities
for emergency response, and were even further removed from responsibility for plant operation. Regardless, they did become involved as they foundout more about the plant status.
The GPUSC participants uniformly stressed intheir interviews that they were severely hampered
by a lack of timely and accurate data concerning
plant status. I ndeed, although their afternoon
recommendations and diagnoses turned out to beappropriate, they have stated that they had suchmeager data that they were not at all certain of thebest course of action. Among the contributing factors were the nature of the reports from the control
room and a reluctance to take the operators' timeby asking for additional data, both of which could be
resolved by planning for offsite diagnostic support.

I nputs to Arnold

Wilson became concerned about core coolingaround 10:00 a.m. when he learned that the reactor
coolant pumps were off. He called Keaten from ameeting to discuss the situation. Keaten also recalled being concerned about core cooling and theefficacy of natural circulation from the time he foundout that the reactor coolant pumps were off. Someti me later, probably in the afternoon, he found outthat the hot-leg temperature indicator was pegged
high. A brief analysis indicated superheated steam,i mplying the likelihood of a steam bubble, an uncovered core, and failure of natural circulation. He
remembered drawing curves in Arnold's office to ill ustrate the point.
Wilson did not recall a consensus during the dayon what action should be taken, but did recall that
he and Keaten always felt that the reactor coolant
pumps should be run to establish forced cooling
flow. Wilson and Keaten did not recall being awareof the operators' plan to establish core cooling water flow from the high-pressure injection pumps,
through thecore and out of the pressurizer relief or
66,67vent valve.

j. Decision to Repressurize

At about 4:30 p.m. on March 28, Herbein, Miller,
and Kunder returned from Harrisburg. Arnold discussed plant operation with Herbein and strongly
recommended that the plant be repressurized andthat a reactor coolant pump be started. They
agreed on this course of action and Herbein agreed
to direct the plant staff to carry it out. Herbein recalled steam in the hot legs and the lack of successi n an earlier attempt to depressurize and operate
the decay heat removal system as major reasonsfor the decision. Arnold also recalled that an important consideration was the desirability of returning
to a mode of operation that they understood well. 68
Herbein imposed this decision on Miller and theplant staff who favored continuation of the low pressure strategy. The decision constituted a positive
contribution by management in that it established astable core cooling mode that would be maintained
for about 3 weeks.

839

i ng prescribed procedures, was based on the containment dome monitor reading and an assumed
containment leak rate. It then projected dose rates
greater than 10 R/h off site, a startling and unbelievable figure. Of course, this was merely a reflectionof the radiation monitor reading and the assumed
leak rates. The dose rates were checked by fieldmeasurements and the high values did not materialize because the containment was not leaking as
much as had been assumed in the calculation.
However, knowledge of the result of the calculation
might have emphasized how startlingly high thedome monitor reading was and possibly could have
led to further consideration of it.
GPUSC personnel were not aware of the leaking
PORV and the throttling of high-pressure injection
flow, which had caused the core damage. Nor were
they aware of the containment pressure spike (hydrogen burn) that had occurred. The personnel
were also unaware of the offsite radiation releases
and probably not aware of specific radiation readi ngs in the plant that qualitatively could indicate thatthe containment dome monitor reading might becorrect.
Herbein was in a similar situation. He recalled his
impressions as the following:k. Wednesday Night, March 28
I n the evening of March 28, after a reactor
coolant pump was started, personnel at GPUSC
headquarters felt that the accident had been terminated and was under control. GPUSC personnel
generally were aware that there had been problems
with core cooling and abnormal radiation readings,
so they had to be aware of the possibility of somecore damage. However, they have stated that they
did not understand the severity of what had happened. Because they went home at about 9:00 p.m.
Wednesday evening and on Thursday occupied
themselves primarily with organizing an investigation
and analysis program, their actions bear this out.
GPUSC personnel had been aware of hot-leg
temperatures of more than 600°F during the day,and correctly inferred that this implied superheatedsteam and an uncovered or inadequately cooled
core. Knowing this, one could then deduce that thecore might possibly have reached much higher temperatures (above 2000°F) that could cause physicaldisarrangement, significant hydrogen generation, or
both; that is, a metal-water reaction. Arnold statedthat this possibility did not cross his mind and wehave found no evidence that anyone else at GPUSC
headquarters was thinking in these terms.
GPUSC personnel were not aware of an initial setof core thermocouple readings that could haveprompted them to think in terms of severe coredamage. This initial set of several readings included
those as high as 2400°F and as low as 200°F, all inthe same horizontal plane a few inches above thecore. Such variations seemed quite inconsistentand thus, the readings were suspect. However,they did contain a direct suggestion of a very hot
core, and if known might have prompted thinking interms of possible severe core damage.
GPUSC personnel were aware of the containment dome radiation monitor reading, which wasvery high. Upon reflection or calculation, comparing
this reading to predicted readings for design basis
accidents could have indicated that, as a minimum,a substantial fraction of the fuel cladding was
breached-but not necessarily that the core had
undergone extensive physical disarrangement. Arnold believed the reading was probably caused by amoisture problem, partially because the indicatedradiation levels were so high as to seem incredible.
He retained this impression for days. 69 Wilson did
not recall others dismissing the reading, but neither
did they make the connection with a significant fraction of fuel rods being breached.
GPUSC personnel probably were not aware of a
related matter-a projected dose calculation that
had been made at the site. The calculation, follow-

I think we felt a lot better because forced circulation had been restored. We had hoped to go
ahead and cool the system down with the reactor
coolant pump and operating steam generator to thepoint where we could consider going over onto the
decay heat. I think, we recognized we did have fueldamage and that there might want to be a more
i n-depth look at the implications of going over onto
the decay heat system before we actually made the70switch.

Herbein was aware of the initial set of core thermocouple readings, which Miller had reported alongwith the caveat that they were probably not very reli able. 46 This lack of understanding of the extensive
nature of core damage extended in essence to the
NRC, B&W, and the plant operators as well as company management and staff. It continued until lateThursday night to Friday morning.
The core was physically disarranged and to al arge extent this tended to block cooling water flow.
The reactor coolant system contained significant
quantities of hydrogen, which also tended to block
cooling water flow. The situation was markedly different than it would have been with a basically intact
core and some fuel rod cladding perforations.
These factors seriously threatened continued corecooling in the event that the reactor coolant pumps
were lost or the system pressure decreased. Hydrogen also could possibly present an explosion hazard when vented into the reactor building.
840

Measures that could be taken to reduce this risk
were not taken until later when the risks were understood. These measures include the following:

About 2:30 p.m. - Briefing a congressionaldelegation
Later - Briefing another congressionaldelegation 71• Procedures could be developed to guide theSuch activity obviously presented a problem withrespect to gaining a better understanding of true
plant conditions. Herbein stated that he had believed it was a problem, but also something thatmust be done. 72 As with the Lieutenant Governor's
request for a briefing on Wednesday afternoon, we
are not evaluating the decisions by the press andTo ourpublic officials to seek information.
knowledge, they did not have reason to think thatthey should not be briefed because company officials were needed at the plant to assess the true situation. In our view, the responsibility for recognizi ng this need rested with the company.
Herbein recalled checking periodically on plantstatus, authorizing a reactor coolant sample, anddiscussing the need for resources at the site with
Miller and GPUSC. Arnold's primary emphasis on
Thursday was on organizing the investigation,
analysis, and recovery effort. He found out from the
GPUSC engineers at the site that high-pressure injection flow had been cut back and discussed thiswith Dieckamp at about 11:00 a.m. This helped explain the radiation readings that indicated core damage. If the high-pressure injection system had been
allowed to function automatically,
they would not73
have expected core damage.
Arnold andDieckamp also discussed their belief that Herbein
did not know of this as yet. Their perception ofcore damage at that time was cladding perforations
i n perhaps 0.5% or 2% of the fuel rods.
Keaten spent time organizing the investigation,
analysis, and recovery. It was decided to send Wilson and additional personnel to the site. Wilson
would lead the investigation, which would be moreformal than what had been envisioned on Wednesday. Wilson arrived at the site at about 2:00 p.m.,
and at about 5:00 p.m. he met with Miller and others
to discuss the investigation.
One of the subjects of discussion was Wilson's
desire to proceed quickly with operator interviews.
After this meeting, Wilson recalled concluding thatthe situation was worse than had been previously
thought and that as much assistance as possible
should be obtained in bringing the plant under control. As Wilson recalled, this conclusion was notbased on specific evidence of the plant's condition
such as the core thermocouple readings, the hydrogen burn, or the noncondensible gas bubble in thereactor coolant system. He did not know about
these things at the time. Rather, the conclusion was
based on general indications such as the need towear respirators on site, the lack of progress inoperators into the best course of action in theevent of various malfunctions.
• Precautions against both decreasing systempressure and against causing a hydrogen explosion could be taken.
• Contingency plans for early warning on a possible need for evacuation could be made.

As it turned out, core cooling was maintained andno further uncontrolled hydrogen burns occurred.
Thus, although the lack of understanding increased
the risk, the only effect on the course of the accident was to delay recovery.
This matter also affected the public perception of
the accident, in that earlier reports indicated thatthings were pretty well in hand and later reports indicated considerable hazard.
I. Thursday, March 29
On Thursday the plant operators were still running a reactor coolant pump for forced cooling water flow through the core. The core was not cooling
down as expected because it was physically disarranged and there was a substantial amount of hydrogen gas in the system. The makeup pumps
were running to provide seal injection water to thereactor coolant pump seals, and the letdown system
was operating to recycle this makeup water rather
than depleting the inventory in the borated water
storage tank (BWST). Radioactive gas from thereactor coolant system was accumulating in the
makeup tank as a result of letdown system operation. This basic mode of operation would continue
for many days.
Beginning Thursday night, when the noncondensible gas content of the reactor coolant sytem wasrecognized, the operators intermittently degassed
the system by spraying coolant into the pressurizer
and venting the gas from the pressurizer to thereactor building. However, the majority of the gas
was removed from the reactor coolant via the letdown system.
During the day on Thursday, Herbein had aheavy schedule of briefing the press and other public figures. He recalled the following activities:
7:30 a.m. - Taping Television show
10:00 a.m. - Press Conference
About noon - Briefing members of the
Public Utilities Commission

84 1cooling down, Kunder's request for engineering assistance in the control room, some understanding
by GPUSC engineers of the initial stages of thetransient, and perhaps, Miller's feeling that therecovery was not sufficiently complete to allow
operators to be interviewed. Wilson recalled conveying his impression that the situation was worse
than previously thought and that both Arnold andVollmer of the NRC needed a great deal of assistance on Thursday evening. 74
Arnold recalled being told of the possibility of significant core damage; but until he came to the site
on Friday morning he did not realize the extent to75
which the plant was in an unstable condition.
Vollmer recalled agreementthat most of the fuel76
pins had probably leaked.
Thursday evening, personnel in the control roomsuspected that there was a noncondensible gas
bubble in the reactor coolant system. They began
determining the bubble's size
and requested calcu77,78
l ations concerning its nature.
Sometime Thursday night or Friday morning, control room personnel
became aware of the containment pressure spike. 79
The significance of this spike became commonly
known on Friday morning.
m. Friday, March 30: Releases of RadioactiveGas
It is likely that the events of Friday morning andearly afternoon on March 30, provided the mostdisquieting moments of the accident for the
residents of the towns near Three Mile Island.
Shortly after 12:30 p.m., Governor Thornburgh
recommended that pregnant women and preschool
children living within a 5-mile radius of Three MileI sland leave the area and that schools within thisarea be closed. Earlier in the day, Kevin Molloy,
Director of Emergency Preparedness for Dauphin
County, warned citizens during a radio broadcast
that an evacuation might soon begin. It had also become publicly known that a helicopter had measured a 1200 mR/h reading over the TMI-2 vent
stack at 8:01 a.m.
The drama of the day seems to have been the
result of a misperception of the significance of the1200 mR/h reading on the part of NRC staff in
Bethesda, and a misinterpretation by a Pennsylvania
civil defense official of a phone conversation with a
Met Ed employee. It is somewhat ironic that theconcern for public safety arose, not from occurrences within the reactor building that houses
the reactor system and thereby captures the attention of the public, but from problems within the auxi842

li ary building. In the following paragraphs, the workings of several of the systems within the auxiliarybuilding and actions taken by the control room
operators to stem serious difficulties with these systems will be explained. Finally, the effects of theactions will be discussed in the context of the ensui ng evacuation plans.
The Makeup Tank

The makeup tank is a part of the makeup system.
Water is continually removed from the reactor
coolant system for purposes of purification andtesting, and the makeup system replaces this water
i n order to maintain a constant inventory within thereactor coolant system. The makeup pumps pumpwater into the coolant system and inject water into
the seals of the reactor coolant pumps. The makeup tank provides the source of water to the makeup
pumps.
Normally, the letdown and makeup of the reactor
coolant is a fairly routine procedure, but the presence of noncondensible gases-created by the uncovering of the core on Wednesday-severely impeded proper flow in the makeup system. The letdown from the reactor system flows into the lowpressure makeup tank. In the makeup tank, anygases in the water from the reactor coolant
system-including any gaseous fission products
such as krypton and xenon-separate from the water as a result of the lower pressure, and tend tocollect at the top of the tank.
The operators feared an increase in gas pressure
because at 80 psig, the relief valve (MUV-R1) in pipi ng leading from the makeup tank to the makeup
pumps would open and dump the tank water into
the reactor coolant bleed tank. Then, the usual
source of water to the makeup pumps would be lostand suction would have to be taken from the BWST.
This concerned the operators because they considered the BWST inventory an important and a lastreserve source of water in case of another coolingproblem in the core.
A vent valve (MU-V-13) at the top of the makeup
tank (where the gas would naturally collect) leads toa vent header from which gas is pulled out by a gas
compressor into a waste gas decay tank. This ventsystem permits transfer of radioactive gases fromthe makeup tank into storage tanks where radioactivity decays before release to the environment.
Unfortunately, leakage in this vent system allowed
some of the radioactive gases to escape into theauxiliary and fuel handling buildings where theypassed through the ventilation filters of these buildings and up the vent stack to the outside.

vent at 7:10 a.m. No matter how each perceives thei nfluence of his own and his fellow workers' roles,
there is complete accord among them that the venti ng of the gas in the makeup tank was necessary,and the method applied was the best available.
Greg Hitz arrived on site at 6:00 a.m. to relieve
Bill Zewe. Upon entering the control room, Hitz wasi nformed by Faust and Ed Frederick that they "weretrying to hold the pressure in the make-up tank but
weren'tvery
successful
because[it81was]... gradually increasing."
One of the operators said "...we are not keeping up and will have to
do something," and in fact, an auxiliary operator was
getting ready to enter the auxiliary building to restart
the waste gas compressors as the first step in thecycling of the vent valve, a task which had been
periodically required all night. 81 Hitz remembers
closely monitoring the situation at this point, and hei s "pretty sure" the relief valve cycled open and shut
two and three times. Finally, they were unable tokeep the valve from cycling, and the levels in the
bleed tanks continued to rise. Hitz became duly
worried: "My fear was draining the BWST to thebleed tanks and overflowing the bleed tanks
onto
82
the floor of the basement through the vent."
Floyd recalls, "We were still in a situation which
83
When the makeup
we did not fully understand."tank lost all of its water at 4:35 a.m., suction for the
makeup pump had been switched to the BWST.
Why were the bleed tank levels rising as the BWST
level dropped? Zewe best analyzed the quandary:
They didn't perceive how they "were transferring
the water from the BWST into the make-up tanksystem and into the reactor coolant bleed tank.... It[the system] is not designed or intended to function
going from the BWST to the make-up to the bleed
tanks.... That was a path we had never explored
before." 84 Water was being lost from the BWST
through two routes. As letdown flow dumped into
the makeup tank, gas escaped from the reactor
coolant water and kept pressure in the tank above
the relief valve setpoint, so the newly arrived reactor
coolant water went into the bleed tanks. Water was
also flowing into the makeup tank from the pumpminimum-flow recirculation line. This recirculation
li ne allowed the makeup pumps to run even when
they were not supplying water to the reactor
coolant system by allowing the pumps to discharge
a minimal flow of water, which theoretically wentfrom the makeup pumps to the makeup tank andback to the pumps. In this instance, however, thewater entered the makeup tank and was swept
through the relief valve into the bleed tanks.
Zewe was out of the control room being interviewed by GPU personnel between about 5:45 andBill Zewe, the Shift Supervisor on duty from 10:30
p.m. Thursday night until 1:00 p.m. on Friday, testified that the operators were aware of the relationship between the opening of the vent valve and therelease of radioactive gases into the environment.

We could see it off-site. Every time we would vent,there would be about 30 to 40 minutes of a delay
between the opening of the vent to where we could
80
actually monitor external to the plant.

The operators were faced with a dilemma: theywanted to ensure that water was maintained in the
makeup tank, but the best way to do this-the venting of gas to the vent header-caused releases ofradioactive gases into the environment.
A procedure was developed to deal with the conflicting issues. The venting was performed in shortbursts by opening the vent valve until the ventheader pressure reached about 15 psig. The valve
would then be closed until the waste gas compressor pumped the gas from the vent header into thewaste gas decay tanks and dropped the ventheader pressure to about 5 psig. At that point, theoperator would reopen the makeup tank vent valve
until the header pressure again reached 15 psig.
This process was continued until the desiredpressure was achieved in the makeup tank. (Itshould be noted that this procedure required theentrance of an auxiliary operator into the auxiliarybuilding to start the waste gas compressor. The
operator had to wear respiratory protection equipment to protect himself from airborne radioactive
materials in the "aux" building.) This method of reli eving the makeup tank of some of the noncondensible gases, while not allowing pressure in the ventheader to get too high, minimized the releases of radioactive gas into the auxiliary building-and subsequently to the outside atmosphere-and kept thepressure in the makeup tank below the relief valve
set point of 80 psig.
At 4:35 a.m. on Friday, the very thing the operator had been trying to avoid happened: the relief
valve opened and all of the water in the makeup
tank ran into the reactor coolant bleed tank. The
operators were forced to transfer suction to the
BWST and face the possibility of a loss of their primary source of borated water.
Beginning of Continuous Venting

Testimony does not always coincide as to therole of the personnel involved in the opening of ventvalve (MU-V-13), but one thing is certain: only fourmen-,James Floyd, Bill Zewe, Greg Hitz, and Craig
Faust-played significant parts in the decision to84 3

7:00 a.m. He was absent from the control room
when the different tank levels began to indicate aserious loss of water from the BWST. Floyd beli eves that when Zewe returned to the control room,
Zewe quickly noticed the increasing level in the
bleed
tank-somethingtheothershadoverlooked-because he had not looked at thegauges in at least an hour and a quarter, so for him
the cumulative rise in level was noticeable. 85 Zewestated that when he returned to the control room,
he was apprised of zero level in the makeup tank, a
2- or 3-foot loss from the BWST,
and bleed tanks
86"overflowing with a high level."
A decision was made at this point to open thevent valve. Floyd testified during a public hearing
before the President's Commission that he orderedthe valve opened.87 Zewe, Faust, and Hitz havetestified that Floyd had no active role in this decision 88 On September 13, Floyd, aware of the testi mony of the others, stated "whether the operator[Faust] was looking at Mr. Zewe or looking at me atthat particular moment in time, who he took his instructions from at that particular moment, I don't
know."89 The extent of Floyd's role in the venting
order, in no way changes the fact that no one in thecontrol room disagreed with the plan, and all fourmen directly involved advocated the action.
Another disagreement in testimony arises overthe question of just when it was decided to continuously vent. Floyd claims that from theoutset, he
90,91
thought in terms of continuous venting.
Floyd's
version is contradicted by Zewe and Hitz. Zewe initially wanted to simply reseat the relief valve and hei ntended to shut the vent valve when makeup tankpressure decreased to 65 psig. When 65 psig was
attained, Zewe, "under strong urging from Mr.
Faust"92 and after conferring with Hitz, decided tol eave the vent open and monitor the radiation levels.
I n this manner, they would "then just take the gasbuildup in small puffs from thereon instead of agreat big release every so often." 92 Zewe, Faust,and Hitz tend to agree on the circumstances surrounding the venting. Because they were working
at the control panel during the procedure, we cancautiously assume that the decision to leave thevent open evolved both as radiation readings werestudied; and as the advantages of small, continuous
releases of radioactive
93material were compared withl arge, acute releases.
Once the pressure in the makeup dropped below
80 psig, the relief valve reseated and the operators
turned on two demineralized water transfer pumps
i n order to get water into the makeup tank by thequickest means available. This enabled them toswitch suction for the makeup pumps from the

BWST to the makeup tank. Eventually, the wastetransfer pumps were used to pump water from thereactor coolant bleed tanks into the makeup tanks,
thus resolving the problem.
Although the continuous venting that started at
7:10 a.m. had some unfortunate byproduct as regards the evacuation concerns, from an operating
standpoint the venting seems justifiable. Floyd wastroubled over losing the "one source of water
between me and another LOCA." 94 Floyd alsofeared the release of radioactive gas through thereactor coolant bleed tanks, "If we were relieving
the gas through that route, it was all going out to the
public." Floyd believed that releasing radioactive
gas through the vent valve meant that at least someof the gas would end up in the waste gas decay
tank, hence lessening offsite releases. 95 Faust
feared a loss of BWST inventory. Hitz also worried
about the BWST inventory and had as a "first priority" the prevention of the overflow of the bleed tanks"back throughthe vent lines, into the traps, and on96
the floor."
A loss of BWST inventory could have forced the
makeup system to have been placed in the recircul ation mode from the reactor building sump. This
would have resulted in contamination of otherpumping equipment and possibly caused the releaseof radioactive material into the environment becauseof equipment leaks.
Furthermore, alternate methods of relieving gas
from the makeup tank looked less desirable thanthe continuous venting procedure. Letdown andseal return flow to the makeup tank could havebeen stopped, consequently arresting gas buildup in
the tank; but securing of the seal return flow increased the probabilityof seal failure on the reactor
97
coolant pumps.
It should be added that after Friday, copper tubing, which passed between the makeup tank andthe reactor building, was installed. Gases from the
makeup tank could then be directed into the reactor
building, which acted as a large gas storage tank.
This line was never used, but Floyd has testified
that if it had existed on Friday, he would have preferred using the line to the venting procedure-if it
had no leaks. Such a line would have precluded thetroublesome releases of radioactive materials to theoutside. 98
Assessing the judgments and actions of the Met
Ed employees against the backdrop of the drawn
out nature of the accident, the unforeseen difficulties
encountered by the operators, and the necessity ofbalancing limited radioactive gas releases with adesirable makeup tank pressure, we can only con84 4the control room, nor did he know that Hitz had
also called Unit 1 concerning the same subject 104-106
2. After Hitz had been assigned to head the communications effort he asked Unit 1 personnel tonotify PEMA, Margaret Reilly, and Thomas Gerusky of the Pennsylvania Bureau of Radiation Protection of the venting. Neither Hitz nor Zewe
knew what Floyd's activities were at this point,
yet during this period Floyd had the regrettable
conversation with civil defense regarding evacuation readiness.107-109

clude that the operators did what was required ofthem.
Otherlssues

The principal concern until now has been the
response of the control room operators and supervisors to a situation that posed a threat to the stability of Unit 2 and to the health of the public. The
effects of the 7:10 a.m. venting, however, raised
problems for the Governor of Pennsylvania's Office;the NRC Headquarters in Washington, D.C. and
Bethesda; and various local, State, and Federal
agencies responsible for the evacuation plans (notto mention the public, who experienced unnecessary apprehension). Therefore, we explored thepart that the Unit 2 control room personnel played in
the evacuation scare.
During a now famous conversation, James Floyd
spoke to a Pennsylvania Emergency Management
Agency (PEMA) official, and to use Floyd's own
words, "... maybe one of the classic miscommuni99
The
cations of all time took place at that point."
official interpreted Floyd's words to mean that Unit 2
had an uncontrolled release and PEMA should be
prepared to evacuate people situated downwind of
the plant. Coupled with the "horrible coincidence"i nvolving the 1200 mR/h reading (wherein NRC
Headquarters misperceived the cause and locationof the reading) and Floyd's contacts with the civil
defense personnel, his words undoubtedly produced
an ingredient that aided in the distorted sense ofthings that followed. 100
Friday was a day plagued with horrendously poor
communications, and this problem can even be seenamong the people in the Unit 2 control room. Gary
Miller, who was on site early Friday morning, wascontacted by Mike Ross regarding the venting andradioactive gas release. When Miller arrived in thecontrol room around 7:30 a.m., he put Zewe incharge of plant operations, whereas
Hitz was
101,102
responsible for communications.
Unfortunately, before and after the delineation of duties, Hitz
and Floyd were duplicating communications tasks;
Floyd's call to civil defense personnel bypassed thenormal communication channel that had been established through the emergency control station.
Floyd, however, said that in prior drills he had103
frequently made the call to the State civil defense.
Following are some examples of the poor communication on that day.

The above examples would appear as mere quibbles, however, to the public most affected by thepoor communications. In the context of Friday's
events, these examples clearly portray the need fora planned and accurate dissemination of informationfrom the control room to the emergency control station and to Government agencies. Not only will an
accurate flow of reliable data be maintained throughthe implementation of such a plan, but a minimal
number of people will be needed to distribute the information. As Floyd said, "I wasn't happy about
having to be on the phone in the first place. I would
have much sooner been in the control room listening
to the radiation levels, so I was hurried.... As for thepace of the conversation [with PEMA], it may havebeen hurried because I was in a hurry to get off thephone.""o In addition, all communications planningshould be developed with a view of the type of protracted accident that occurred at Three Mile Island.
From this experience it seems that communicating
gets more difficult and more subject to obstruction
as time goes on.

n. Beginning of Recovery
On Friday, March 30, several factors combined
to make the company management and staff awareof the nature and seriousness of the remaining
problems in the plant. Problems associated with thebuildup of radioactive gas in the makeup tank had
resulted in offsite releases, which were quickly andwidely reported by the news media.

The containment pressure spike on March 28
and its diagnosis as a hydrogen burn became generally known. The existence of high core thermocouple readings on March 28 and the hydrogen gas
content in the reactor coolant system also became
generally known. The GPUSC engineers had completed a fairly accurate analysis of the initial sequence of events that had caused the core damage.

1. Floyd requested that a helicopter monitor
releases "immediately after the fact (of venting),"but he did not discuss the request with anyone in945

An organization to assist in the recovery started
evolving on Friday. With respect to technical support, GPU engineers were stationed in the control
room to gather information and to assist in understanding plant conditions. They reported to T.
Gary Broughton, GPUSC Manager of Control and
Safety Analyses, in a trailer on site, and he in turnreported to Wilson in a trailer off site. These activities were maintained 24 hours a day from that timeon. The groups eventually became those labeled 1,
2, and 3 on Figure 111-3, which shows the recovery
organization.
At GPUSC headquarters there was a rush of activity to answer requests for engineering informationfrom the site. These activities also took place on a
24-hour basis. Similar activities were taking placeat Burns and Roe headquarters (where the plant
was originally designed), and at B&W headquarters.
Eventually, many of the GPUSC engineers weresent to the site and absorbed into the technical support organizations there. Much of the Bums andRoe effort came to be the plant modifications group,
l abeled 4 on Figure 111-3. B&W set up an onsite
group (not shown on Figure 111-3) in addition to providing technical assistance from its headquarters.
The management began requesting personnel
from outside the company to assist in the recovery.
Dieckamp requested assistance from nuclear industry sources such as the Electric Power Research Institute, utilities, nuclear steam system suppliers,
architect-engineers, and consultants; Government
agencies and laboratories such as NASA, Oak
Ridge and Argonne; individuals such as N. J. Palladino, Dean of Engineering at Pennsylvania State
University; Sol Levy, nuclear engineering consultant;and from companies such as the Electric Boat division of General Dynamics. Also on Friday, the NRC
arrived in force, began taking an interest in plant
operations, and-parallel to Met Ed's efforts-began
requesting outside personnel for assistance.
The response to these requests for assistancewere massive and rapid, with hundreds of people onsite during the weekend. On Wednesday, April 4,
Dieckamp drafted an organization chart for therecovery organization, which essentially formalized
the functions that had been evolving since Friday
and corresponded to Figure 111-3.

early decision not to change the core cooling mode,
unless necessitated by a problem such as a loss ofreactor coolant pumps, because the existing mode
was known to be stable and effective, at least in the
short term.
Early recognition that the long term goal was natural circulation, and that the reactor coolant systemshould be degassed to allow natural circulation towork was another major feature. This followed fromrecognition that, in time, reactor coolant pumps orother equipment vital to the existing mode would
li kely fail, probably because of the radiation levels
i nside the reactor building.
The reactor coolant system was degassed primarily by the removal of gases from the letdown
flow through the makeup tank and venting to thewaste gas vent header, and by spraying coolant into
the pressurizer where a significant fraction of thehydrogen gas would separate from the liquid
coolant. Next the gas was vented from the pressuri zer into the reactor building. There were some earl y "fits and starts" to this latter procedure when the
NRC, taking a more conservative view than thecompany, was concerned that an explosive concentration of hydrogen might build up in the reactor
building. However, these differences were resolved
and it was not necessary to delay this degassing
technique until reactor building hydrogen recombiners were installed.
Some degassing also resulted from continued letdown system operation. Gas accumulated in the
makeup tank and was pumped to the waste gas
storage tanks, from where it was eventually vented
back into the reactor building. Leakage in the letdown and waste gas systems gave continuing
releases of radioactive material from the plant vent.
Although the releases were not large enough tothreaten public health, measures such as installationof additional charcoal filters in the auxiliary building
ventilation system were taken to reduce them.
There was, for a time, a disagreement between
NRC and Met Ed about whether or not the hydrogen
bubble could explode inside the reactor coolant
system. No explosion was actually possible because of lack of oxygen. Such an explosion, if itwere to occur, would raise the possibility of further
disarrangement of the core and the possibility ofdamage to the reactor coolant system. This dispute
was resolved by about Sunday night. Regardless ofwhether or not the bubble could explode inside thereactor coolant system, the common goal was always to get rid of the gas bubble.
Numerous contingency questions were addressed. For example, plans and procedures wereo. Recovery
Once the recovery began, the hazards were generally recognized and appropriate actions were taken to eliminate them. One major feature was an
84 6

FIGURE 111-3. Company TMI Recovery Organization

84 7

Deputy. Robert Arnold headed the technical operations aspects of the recovery with Byron Lee, aVice President of Commonwealth Edison, serving as
Deputy. Richard Wilson headed the GPU technicalsupport effort-providing engineers in the control
room, analyzing off-normal conditions that existed
or might exist, developing procedures, gathering andanalyzing data, and developing requirements forplant modifications.
The modifications were
designed by the plant modifications group, consisting of Burns and Roe personnel and headed byWilliam Cobean, a Vice President of Burns and Roe.
Actual plant operations were handled by Herbein's
groups. The Industry Advisory Group (IAG) was a"think tank" type of operation consisting of high level industry representatives. All of the groups werevery heavily reinforced with outside personnel sent
to assist in the recovery. The NRC and B&W organizations, which are not shown on Figure 111-3,
also played significant roles. Thus, the overall
recovery represented a joint industry and Government effort.

developed on how to respond to equipment failures,such as losing a reactor coolant pump or pressurizer level indication. Estimates were made of how
long critical equipment might remain functional in theradiation fields inside the reactor building. Studies
were also made of various alternative scenarios that
could occur if the situation were seriously degraded.
Conditions such as flooding the containment to cool
the core could be set up if it became necessary.
If the reactor coolant pumps had all been lost before degassing made natural circulation feasible, theECCS could have been used for core cooling. However, this probably would have resulted in increased
releases of radioactive materials because of inherent leakage in portions of the piping systems
outside the reactor building. After the plant was degassed and cooled down, the decay heat removal
system could have been used as well but with similar inherent problems of releases of radioactive materials through leaking components. Construction ofa leak tight analog of the decay heat removal system was begun to eliminate the leakage, if this modeof cooling became necessary.
Construction was also started on a leak-tightbackup system to circulate cold water through the B
steam generator. Its purpose would be to provide adriving head for natural circulation, without the needto depend on the regular installed plant systems andwithout their inherent leakage characteristics. In
addition, a backup piping system was built to provide stable and positive control of plant pressure
without reliance on the pressurizer level instruments
inside the reactor building. This system was eventually put into service when the pressurizer level instruments failed.
In considering various recovery actions, theconsequences were evaluated before the actions
were taken. For example, when the reactor buildinghydrogen recombiners were placed in service, considerable planning effort was devoted to precautions
against causing a hydrogen burn or explosion because there was uncertainty about the hydrogenconcentration in the reactor building. Similar precautionary efforts were devoted to venting the radioactive gas waste storage tank contents back into
the reactor building because these tanks contained
considerable quantities of hydrogen. It was possible
the tanks also contained significant amounts of oxygen, which not only indicated a need to prevent setting off an explosion, but also to get the gases backinside the reactor building.

Decisions were discussed in meetings of theTechnical Working Group (see Figure 111-3). At
these meetings, senior representatives of the various groups-including NRC, B&W, the GPU technical support group, and the Met Ed operationsgroup-met to propose and discuss actions. Company personnel chaired the meetings and were
responsible for making the decisions. A consensus
was achieved for most decisions. The NRC, by virtue of its legal authority to issue orders, did havethe authority and, therefore, implicit responsibility tooverride a decision whenever that seemed necessary.

Key GPU personnel involved in the technical support effort believed that the NRC presence was
helpful. Their impression was that, generally, NRC
personnel were working on solving the problems
rather than taking the more usual regulatory stanceof reviewing and criticizing proposals made by others, without responsibility for expediting theschedule. They perceived constant pressure fromthe NRC to get things111.112
done quickly to move on withthe job of recovery.
In contrast, William Lee
perceived
theNRC
presence
as having the opposite
113
effect.
As can be expected with hundreds of additional personnel assisting in the operation, there
was confusion. With regard to framing the organization, for example, Dieckamp stated:
Wednesday morning [April 5] Warren Owen andJohn McMillan grabbed ahold of me and said,' Look, we have got to organize this thing.' We
closeted ourselves and began to lay out the organi-

As indicated on Figure 111-3, the organization washeaded by Herman Dieckamp with William Lee, aVice President of Duke Power Company, serving as

84 8

zation structure that ultimately became established. 114

leaking PORV). Furthermore, the high-pressure injection system tried to do this automatically but it
was bypassed and overridden.
Even lacking such understanding, had the LOCA
procedure come to mind and been followed, highpressure injection flow would have been maintained,
preventing serious core damage. A reactor coolant
system pressure decrease and the presence of water in the reactor building (both conditions were evident in the control room) are two classic symptoms
of a small loss-of-coolant accident.
A good explanation for the low pressure was notfound. There was ample evidence, available andknown to the operators, that the PORV was leaking.
For a variety of reasons, they misinterpreted the information to conclude that the PORV was not leaking, and then left the block valve open rather thanclosing it as simple prudence would dictate, or inaccordance with the procedures established forcorrective action upon detection of high PORV
discharge pipe temperatures.

Although we have not performed detailed evaluation of the many decisions made during therecovery effort with respect to placing the reactor ina safe shutdown condition, it is obvious that the decisions were successful, and involved effective andprudent consideration of the problems and alternatives. A later section of this report gives a more detailed discussion of industry support in the recovery
operation.
p. Diagnostic Capabilities of Plant Staff
We believe that the diagnostic capabilities
demonstrated by the plant staff and those whocame to their assistance during the first few hoursof the accident were weak.
This should not be taken as placing the entire
responsibility for the accident upon the operating
staff. Heavy burdens of responsibility must beborne by the NRC, the utility management, thedesigners of the reactor and plant systems, and by
However,a complacent industry in general.
whereas the operating staff can be considered as
the last link in a chain of responsibility, they are
essential to safety.
In evaluating the plant operating staff's performance during the first day there were instances offailure to grasp the basic significance of facts thatwere well known for long periods of time, and whichshould have been understood. Failure on the part ofthe crew to grasp the significance of the low reactor
coolant system pressure at the time of the accident,
for example, was nearly universal. This was largelya failure to get back to basics. The need to keep
the pressure high is a fundamental design conceptof a pressurized water reactor; it is the reason for
the name. The pressure was well known to beanomalously low. It should have been understoodthat when the pressure gets low, the hot water inthe system will boil, and if this goes very far, corecooling will be ineffective. The result is analogous
to what happens when the cap is removed from the
hot pressurized radiator on a running automobile
engine.
The corrective action, full high-pressure injection
flow, should have been evident to a group of individuals who had spent most of their adult lives "living"with pressurized water reactors. Had this measure
been taken at any time during the first 1 1/2 or 2hours, the severe core damage could have been
avoided (even without recognizing or isolating the

Had the block valve been closed early in the accident sequence, perhaps before 10 or 20 minutes
had elapsed, the entire problem would have been
eliminated. Later, perhaps in the first hour and ahalf, recognition that the PORV had not closed
should have alerted the staff to the fact that theplant had been undergoing a long term, small lossof-coolant accident, and that there was need forhigh-pressure injection flow to protect the plant andthe public.

There were also some apparent weaknesses on
the part of those who came in to assist or takecharge of the operating staff. The primary examples are an early failure to understand low pressureand high temperature in the reactor coolant system,
and later in the day, the development and implementation of the erroneous core flood tank theory.
Although they didn't have as much time as the shiftcrew to think about it, the conference call participants (Herbein, Miller, Kunder, and Rogers) missed
the significance of the low reactor coolant systempressure and high temperatures at about 6:00 a.m.
Later in the day, the entire emergency command
team apparently endorsed the questionable coreflood tank theory, which could only result from al ack of knowledge of plant design and arrangement
or comprehension of the simple physical principles
i nvolved.
Part of the reason for management's failure wasits ready acceptance of the correctness of theoperators' interpretations and actions. A prudent
amount of management skepticism would have been
truly enlightening. For example, during the confer84 9

ence call a simple approach of skeptical operating
staff questioning would have likely brought forth
further information, readily available to the group in
the control room. This information should have permitted the conference call participants to determinethat the PORV had been leaking and was the causeof the low pressure. However, the participants accepted the simple report that the block valve wasclosed, presumably assuming that the operators had
this area well in hand. In another example later inthe day, many of those involved had a great deal of
difficulty believing the worst-that the core was uncovered, badly damaged, or both-despite indications such as radiation levels, hot-leg temperatures,and possible high core thermocouple temperatures.
The qualifications of some of the key personnel
selected by management suggest that management
did not really expect these supervisors to step inand independently diagnose plant operating conditions and to either assure that the operators' actions were correct or to provide direction to correct
operator errors. Had this involvement been expected, the key personnel for such operating decision
backup could have been predesignated, and the individuals could have studied to become expert on
the plant details and accident considerations. They
could have had current operating licenses and received training by actually checking operator actions on the simulator.
A brief summary of some of the key individuals'
qualifications is provided below. Emphasis is placedon the areas that indicate whether or not the personnel had trained themselves as completely as
they might have on plant details and operations, andif they had really expected the need to perform independent diagnoses and make independent
operating decisions.
Kunder, a graduate engineer with 15 years of nuclear experience, arrived on site about 4:50 a.m.
He was the on-call duty officer and later was amember of the emergency command team. He had
held an operating license on Unit 1, which is a similar
plant with somewhat different details and a different
control room. Although Kunder was in training for alicense on Unit 2, he neither knew the details as wellas he did for Unit 1, nor sufficiently well 115,16
to be comfortable about actually operating Unit 2.
Evenafter reviewing the situation for nearly an hour prior
to the conference call, Kunder was not in a position
to discern and correct the basic operating error atthat time (lack of high-pressure injection to mitigate
the low pressure).
Logan, a graduate engineer with 20 years of experience operating naval reactors, which in detailed
design are different from the TMI-2 plant, arrived onsite about 5:45 a.m., as the reactor coolant pumps

were being secured. He was in charge until Miller
arrived, and was later a member of the emergency
command team. Logan had spent about a year
qualifying for a senior operating license on Unit 2,
which he obtained about 4 months prior to the accident. Although this time was obviously adequate
to obtain a license, we would not consider it ample
to really master the different details of a newer andmuch more complex plant. After reviewing the plantstatus for nearly an hour, Logan wanted to get thereactor coolant pumps running. (The same conclusion was reached independently by the conference
call participants at about the same time.) By itself,
we consider this reasonable in that it was an attempt to force cooling water flow through the corewhen the core was not being cooled. However,along with the others, he missed the significance ofthe low pressure.
Ross, who also became a member of the emergency command team, arrived on site about 6:20
a.m. He had considerable experience both as anenlisted man operating naval nuclear plants andoperating the TMI plants. He was licensed tooperate both units and had been a shift supervisor
until his promotion to Unit 1 Operations Supervisor
about 3 months prior to the accident. Approximately the time he arrived, the PORV was being isolated
and it was known that the PORV had been open fora long period of time. Even so, Ross did not perceive the true significance of that information; that asmall LOCA had been occurring for hours and it
was imperative to initiate full injection flow.
Leland Rogers, the B&W Site Manager, also had
considerable experience as an enlisted man operati ng naval reactors. He had been at the TMI station
for more than 6 years and should have had expert
knowledge of details of plant construction. However, Rogers had not been trained or licensed as an
operator on B&W commercial reactor plants.
Rogers participated in the conference call at 6:00
a.m., and later reported reactor coolant temperature
to B&W headquarters in Lynchburg, Va., as about
300° F. That was, however, the cold-leg temperature. It was not until about 1:30 p.m. that B&W
found out about the high hot-leg temperatures. (Itmust be noted that it was not considered B&W's
responsibility to provide qualified operators to stepin and correct problems during emergencies.)
Miller, who was in charge and who arrived on site
about 7:05 am., was a graduate engineer withseveral years of startup and test experience both innaval reactors and at TMI-1 prior to moving up into
TMI management. Although Miller held an operafing
li cense on Unit 1 for 6 months, he had spent little
ti me operating the Unit and had never been licensed
on Unit 2. Aside from missing the significance of850

cy operating procedures-contain information onplant operation to mitigate accidents. We do notmean to imply that this information should be condensed and included in the emergency plan, butrather that more explicit consideration needs to begiven to the assignment of definitive responsibilities
for those emergency managers who will make thedecisions related directly to reactor plant stability
and who will back up those decisions. The emphasis was on radiological aspects, including assessment of any releases of radioactive materials
that might be occurring, and the communication ofthis information to civil authorities. This situation
was usual, rather than unusual, with respect to formal emergency planning.
I n the TMI-2 accident the plant staff failed tounderstand plant conditions over a period of many
hours. During this time, the flow of meaningful plantdata to the management and staff, particularly to
GPUSC, was meager. (B&W Headquarters and NRC
Headquarters had similar problems getting meaningful information.) Once GPUSC did get some key
plant information, the basic core cooling problem
was diagnosed and appropriate corrective action
was recommended. This suggests that a formal
plan to transmit plant data to a group of experts off
site, in order to back up the operators' diagnoses
and actions, would be helpful. An alternate suggestion is, of course, to upgrade diagnostic capabilities
on site.
The plant staff and others in the control room did
respond to numerous offsite requests for information that day-so much so that it appeared
burdensome-and a great deal of information was
117transmitted.
The problem was in getting out themore meaningful information. For example, thehot-leg temperatures, which were key indicators of
the existing problems, were generally slow to be reported off site. The core thermocouple readings,
which complemented the hot-leg temperatures,
were reported only to Herbein. The open state of
the PORV and the throttling of high-pressure injection flow, which were the original causes of the
problems, were not reported off site. The containment pressure spike was not reported. These factors suggest that an effective plan for offsite datatransmittal to provide backup for the operators' diagnoses should attempt to: (1) get the informationout without burdening the operators, and (2) get out
basic plant information independent of or in addition
to what the reporting person perceives as significant. These goals could be furthered by use ofdata
designated communicators, mechanizedtransmittal, or both.
However, in discussing this, it must be remembered that the severe core damage began occurringl ow pressure along with the other conference callparticipants, Miller had no part in the early operating
errors prior to core damage. Later in the day, thel ack of detailed Unit 2 knowledge could have contributed to such things as the lack of specificity inMiller's high-pressure injection order in the morning,or his endorsement of the core flood tank theory in
the afternoon.
There were some bright spots concerning diagnostic capability. A few minutes after arriving at
6:00 a.m., Mehler diagnosed the low pressure asprobably being caused either by failed pressurizer
heaters or a pressurizer leak, and he initiated actions to close the PORV block valve and to checkthe pressurizer heaters. This solved part of the
problem.
After turning his attention to plant operation atabout 7:45 a.m., Miller directed that the highpressure injection system be allowed to operate,
which appears to be a basically sound decision taken for sound reasons. Similarly, the decision to increase pressure at about 9:15 a.m. (in conjunction
with high-pressure injection flow) apparantly was abasically sound decision. As it turned out, however,it was not feasible to condense all of the gas bubbles at that time because of the hot, damaged core
and the presence of hydrogen.
These bright spots with respect to individual diagnostic capabilities are relatively isolated, and onbalance, the operating staff and its management
must be found severely deficient in this basic need.
As stated previously, the fault is not the operating
staff's alone. Responsibility must be accepted inl arge measure by the NRC, the utility management,
and the plant designers. Immediate actions must be
taken to improve and upgrade the qualifications andtraining of operating staffs at nuclear plants, and to
substantially improve the diagnostic capabilities ofboth the plant's operators and operations supervisors and managers. These steps must be taken in
addition to corrective actions to improve plantdesigns, to incorporate human factors considerations in the designs and operating procedures, toprovide for immediate offsite expert diagnostic assistance, and to increase regulatory surveillance.
q. Prior Planning for Early Offsite Support
Before the accident, the early emergency planning did not assign any significant responsibilities tothe offsite utility management and staff; these wereassigned to the plant staff. Nor did the formal emergency planning emphasize plant operations to mitigate emergencies. Reactor operating practices,
procedures, and training-particularly the emergen85 1

As alluded to in Denton's testimony, a part of theconcern may have been the NRC's perception thatthe company didn't have enough answers quickly
enough. Somebody in the company may have been
thinking of what to do in certain circumstances, but
no procedures had been developed and Denton was
unaware of this. A larger part of the problem appears to be the delay in mobilizing the resources
available and applying them to the problems thatexisted. As discussed previously in this report, theutility management believed that the situation wasunder control. Much of Thursday was spent briefing
the press and public figures and planning for an
orderly investigation, analysis, and recovery processrather than following plant operations and applying
technical support resources. Thus, on Friday when
Denton arrived, the company was only beginning its
technical support effort. Finally, of course, thedemands of the accident for technical resourcesand evaluations were great. As Eisenhut stated, thecompany did need a great deal of assistance, which
was obtained and used.
NRC staff officials did not rate the company asparticularly weak in comparison to typical or mediannuclear utilities. Case placed the company in the
middle of three categories of utility technicalcompetence-toward the lower half of that middle
124
group.
Eisenhut envisioned two groups of utilities, a small group in the first category and a large
group in the second category of utility technicalcompetence. He placed the Three Mile125
Island utility
somewhere in the large second group.
Although the Special Inquiry Group has not performed a detailed comparative study, it is also ourjudgment that in terms of the numbers and experience of technical personnel available, including thati n GPUSC, this utility is not particularly weak incomparison to a median utility that operates a nuclear powerplant. In fact, we would judge this utility
to be better than the median in these terms.
We believe that the demands for technical assistance associated with this accident provide clear
evidence of a need for improved capabilities tomarshal and apply technical support resources tothe long term recovery effort (that is, after the firstday) by using company and outside personnel. This
need is believed to exist in other utilities as well.

about 2 hours after the initial feedwater transient.
Considerable effort and expense would be associated with planning to provide reliable and effective diagnostic backup within 1 to 2 hours of a transient,particularly when the operators do not realize that aroutine transient is turning into an accident. The
TMI-2 accident would have required some form ofcontinuously manned monitoring station to check on
the operator's actions without any clear signs oftrouble to prompt such checking, and which detected the plant trip and then independently determined
the plant conditions. Immediate offsite monitoringmight also allow onsite personnel to feel lessresponsible for taking the correct actions because
they would know immediate help was available. The
operating staff must be assigned clear front line
responsibility for the safety of the plant and the
public. The offsite expert diagnostic support must
be advisory, encouraging utility management to insist on a high quality operations staff, and to impress upon each individual supervisor and manager
the vital need to upgrade and maintain his or her individual capabilities for sound diagnostic assessment.
r. Prior Planning for Longer Term Offslte
SupportDuring the first few days after the accident, remarks were made by NRC personnel indicating that
Met Ed's technical capabilities were thin.'$ It appears that such remarks were based on the NRC's
perception of the company's performance in relation
to the needs of the. accident, rather than comparing
the numbers and experience of the company's
technical personnel to those available in other utilities.
Denton and his NRC colleagues were concerned
about the amount of planning for contingencies.
Denton noted that although company personnel
might have been thinking about contingencies, there
was nothing in writing and there were no procedures. Denton stated, "I wanted GPU to get into
the mode where they could answer any question my
119
Case believed there were indicastaff raised..."tions that should have propelled company personnel
120
i nto different courses of action than those taken.
Grimes stated that later in theaccident, the com121
pany lacked critical faculty.
Eisenhut indicatedthat the company needed technicaltalent to help
122
them through the emergency.
Hendrie did contact Creitz to ensure that the company would ask
for whatever technical assistance was needed, as it
was available in the nuclear industry.
He was told
123
that this was already underway.

s. Summary of Findings andRecommendations
Findings

The crew on shift during the first 2 hours after
the accident began, failed to properly diagnose
85 2

•

•

•

•

•

•

basic plant information that was known to themand failed to follow appropriate procedures or
prudent operating practices, any of which would
have prevented severe core damage and madethe consequences of the accident insignificant.
Their actions demonstrated fundamental anddeep weaknesses in diagnostic capabilities,
knowledge, and training with respect to basic
reactor safety concepts.
At 2 hours and 18 minutes into the accident,
when the loss of coolant was stopped, the core
was being severely damaged and partial fuelmelting was probably quite close. A series ofsound decisions by incoming supervisors and automatic actions that served to improve the situation then began. Although it was too late to avoid
core damage and not all the appropriate steps
were immediately taken, these actions did avoid
the immediate fuel melting problems.
There was no system available that had been
designed to cool the core after severe core damage and there was no procedural guidance on
how to attempt core cooling in the event of suchcore damage (or even in the event of natural circulation blockage with an undamaged core).
Although the plant staff did not realize that thecore was badly damaged, they did recognize that
normal cooling methods were inadequate and attempted to cool the core with improvised
methods. The task was difficult. Improvised
methods that were reasonable, with or without
core damage, did not appear to work.
Plant staff supervisors shared in the early failures
to diagnose the basic plant problems. After coredamage had occurred they made some sounddecisions and these helped prevent fuel melting.
Some errors were made later in the day, butthese did not materially worsen the physicalcourse of the accident, except to delay effective
recovery action.
During the day, there was some confusion within
the plant staff and some communication problems within the staff and between the staff andoffsite groups. Some key supervisors were notaware of some significant information. The flowof meaningful information to capable offsitegroups was meager and slow.
There was little, if any, prior preparation for handling plant operations during a postaccident emergency. A reasonable organization was improvised, at the time, to employ the numerous
operators and supervisors available. However,
the organization had not been set up beforehandand had not been trained or drilled. Some key
supervisors involved in operating decisions were
not well prepared to step in and direct plant

operations. Communications within the plant staff
and with outside organizations had not beenpracticed. There was no planning to obtain assistance or advice from offsite groups.
• The failures of plant staff supervisors indicate
basic weaknesses in their understanding of theplant, in their diagnostic capabilities, in the qualifications set for their positions, and in the definition of their duties and organization for plant
operations, and the training and drilling for suchoperations.
• Company management shared in the early
failures to diagnose the basic plant problem andthe plant staff supervisors' errors during the day.
Later on the day of the accident, management
stepped in to direct changes in the plant operating strategy that establishes a stable and effective core cooling mode.
• The management's intervention at that time wassomewhat fortuitous. There was no prior planning for offsite support or review of operating decisions, and the people involved were quite hampered by a lack of meaningful information. Theintervention resulted from the initiative of a large
group of engineers with broad nuclear experience and the actions of two vice presidents withstrong nuclear backgrounds. Not all utilities havestaffs with these capabilities.
• On Wednesday evening and Thursday, there wasa widespread lack of understanding of the extent
of core damage and the remaining threats to corecooling. This increased the risk involved, but because certain critical malfunctions did not occur
during this time, the basic physical sequence of
the accident was not adversely affected, except
to delay recovery actions. The lack of understanding may have altered the public's perception
i n that initial reports indicated things were well in
hand, but later reports were more alarming.
• Although it caused great alarm, the Friday morni ng venting of the makeup tank represented areasonable balance by the plant staff of the risks
and benefits involved in various operating options.
• The utility did not begin to apply its resourcesand outside assistance to the recovery effort inearnest until Friday, when it became generally
understood that significant problems remained.
This slow start, combined with the numerous
demands of recovery from the accident, led NRC
officials to perceive the utility as technically weak
i n relation to the needs of the accident. The utility was not technically weak, however, in compari son to the median nuclear utility.
• Once the recovery began Friday evening, massive resources were brought to bear and it be85 3

came, in effect a joint industry-Government effort. The hazards were generally recognized andappropriate actions were taken to eliminate them,with due consideration of the risks involved invarious options. Appropriate contingency planning was instituted.
Recommendations• Prompt action should be taken to upgrade the di-

•

•

•

•

•

agnostic and emergency response capabilities of
personnel licensed to operate reactor plants, andof their supervisors up to at least the level of unit
superintendent. Whereas these individuals willbe the first to respond to an accident, improvement in their capabilities will provide the mostdirect and immediate improvement in the level ofsafety associated with operating reactor plants.
Accordingly, the recommended action should be
assigned the highest priority.
On the same priority basis, onshift manning levels
should be increased, if necessary, to conformwith levels determined to be needed by the
results of accident response task analyses conducted to define the tasks that may need to be
performed in the event of serious accidents, including those that might involve significant coremelting.
Supervisors of licensed reactor operators, up toat least the level of unit superintendent, should be
required to hold a senior reactor operator license
on any unit to which they are assigned supervisory responsibilities for normal or emergency
operations.
The inplant individual (shift manager or
equivalent) assigned the responsibility for thesafety of operation and in direct charge of theoperators in the control room, should have a coll ege degree in a technical discipline closely related to reactor plant design and operations, and atl east 3 years of operating experience. This requirement should be met as soon as practicable
but not later than July 1, 1983. Exceptions shouldbe rare and rigorously justified.
The duties and responsibilities and the qualifications and training of all personnel assigned tosupport the unit operators and their supervisors
i n maintaining the unit in a state of preparedness,for both effective normal operation and for emergency accident situations, should be reassessed
and upgraded so as to be consistent with the upgraded levels of the reactor operators and theirsupervisors.
Each utility licensed to operate a nuclear plantshould revise its emergency procedures for in-plant response to accidents in order to haveplans available for the organization and efficientuse of off-duty operating staff personnel, who
would be expected to report to the site in theevent of an accident. The procedures should
specify frequent training and drill programs to assure effective emergency implementation of thisorganization.
• Each utility licensed to operate a nuclear plantshould take immediate action to provide theoperations staff with the means to acquire
prompt expert advice from offsite sources in order to better assess and respond to emergency
situations. The plans, organization, and training
for the provision and use of such assistanceshould be based on the immediate implementation of interim measures which should be
developed into a final program approved by the
NRC in accordance with its requirements notlater than January 1, 1982.
• Each utility licensed to operate a nuclear plantshould develop procedural guidance for the useof the operations staff in responding to situations
beyond the normal design bases of the facility.
Included in these guidelines should be procedures for the following:-- cooling a severely damaged reactor or anundamaged core for which natural circulation cooling is blocked;-- preventing containment failure in the eventof a significant core meltdown;-- responding to natural phenomena in excessof those considered in the design bases forthe plant; and-- other events beyond the normal designbases, such as loss of all electrical power.

We do not advocate making all of these events
part of the design bases or developing more
highly detailed and confusing procedures for theoperators to try to memorize. We have in mind
sufficient guidance so that the operators understand what they can do to combat these situations and to make sensible decisions about whichcourse of action might be most effective. Discussions, training seminars, and drills should be conducted to ensure that plant operating personnel
provide input to the procedures and can use
them effectively for guidance in the event ofneed.
• Each utility licensed to operate a nuclear plantshould develop plans for effective mobilization
and use of industry resources for the mitigationof consequences and for recovery from reactor
accidents.

REFERENCES AND NOTES
Floyd dep. at 135-136.
Zewe Interview on March 30,1979 (Met Ed) atl.
3
Scheimann Interview on March 30, 1979 (Met Ed) at 1.
4
Frederick Interview on March 30, 1979 (Met Ed) at 2.
5
Faust Interview on March 30, 1979 (Met Ed) at 1.
6
Zewe Interview on March 30, 1979 (Met Ed) at 3.
1

2

Bryan dep. at 27-28.
NRC, "Investigation into the March 28, 1979 Three
Mile Island Accident by Office of Inspection and Enforcement," NUREG-0600, at IA-40, August 1979.
9
Mehler dep. (Oct. 11, 1979) at 7, 9.
10
Id. at 5-6, 9.
'Pres. Com. Hearing (May 30,1979) at 118-120.
812"Report of the President's Commission on the
Accident at Three Mile Island," Washington, D. C. at 100,
October
1979.
13
TMI Unit 2 Emergency Procedure 2202-1.3, Revision11, 10/6/78, "Loss of Reactor Coolant/Reactor Coolant
SystemPressure," Sections A-3.2.2 and B-3.4 and 3.5.
14
Frederick
Interview on March 30, 1979 (Met Ed) at 5.
15
Zewe Interview on March 30,1979 (Met Ed) at 2.
16
Two basic B&W training manuals are used by the
TMI training group for discussions of plant response totransients. These manuals were reviewed by the SIG
staff at the TMI training office. One was a five part
manual used with videotape, and includes a collection of
i nstrument traces from the B&W simulator showing instrument responses to various plant transients. The second
manual includes discussions of transients and theireffects on the Integrated Control System regulation of thenuclear steam supply systems.
17
Zewe Interview on April 6, 1979 at 10:15 a.m.
(GPUSC) at 4.
18Faust, Frederick, Scheimann, and Zewe dep. at
95.
19
Zewe Interview on April 23, 1979 (IE) at 58.
20
NRC, "Investigation into the March 28, 1979 Three
Mile Island Accident by Office of Inspection and Enforcement," NUREG-0600, Section 4.3.2, August 1979.
21
Zewe Interview on March 30,1979 (Met Ed) at 4.
22Technical Staff Analysis Report to President's Commission on the Accident at Three Mile Island, "Closed
Emergency Feedwater Valves," Washington, D.C.,
October 1979.
23
NRC, "Investigation into the March 28, 1979 Three
Mile Island Accident by Office of Inspection and Enforcement," NUREG-0600, Section 4.2 at 1-4-5, August 1979.

This would be true, at least when the injection rates
are averaged over periods of hours, provided that the
BWST level readings which give such averages are notseriously in error and that the water taken from the
BWST was pumped into the reactor coolant system as itshould have been rather than being lost elsewhere. One
possible but uncommon interpretation of the plant
response data would indicate that much of the apparent
BWST injection water was not pumped into the reactor
coolant system. That interpretation is discussed elsewhere in this report.
37

38

Faust, Frederick, Scheimann, and Zewe dep. at
et seq.
39
Rogers dep., Exhibit 3111 at 12.
41

Summary of telephone conversation between D.
Hunter and D. Allison, December 21,1979.
Faust, Frederick, Scheimann, and Zewe dep. at
et seq.

136

Faust, Frederick, Scheimann, and Zewe dep. at 111.
Rogers dep. at 22.
42
Ross dep. (Sept. 18, 1979) at 16-18.
43
The net injection rate is based heavily on BWST
level decrease. One possible but uncommon interpretation of the plant response data holds that this BWST
water was not pumped into the reactor coolant system as
it should have been, but was lost elsewhere. This possible44
interpretation is discussed elsewhere in this report.
Herbein dep. at 15-16.
45
1d
at 16.
46
Herbeindep. at 17.
47
Herbein dep. at 56.
48
G. P. Miller dep. at 6.
49
Arnold dep. at 27.
50
Herbein dep. at 29.
51
Letter from M. Diaz, Shaw, Pittman et al. to G.
Frampton, SIG, Subject: Response to Request for Information, dated August 7,1979.
52
G. P. Miller dep. (Sept. 20, 1979) at 21-22.
53
Herbein dep. at 26-31.
54
Id. at 31.
40

24
25

numerous recounts of the events that morning.
28
Herbein Interview on May 10, 1979 (IE) at 6-7.
29
Notes taken by John Herbein at 6:00 a.m. on March
28, 1979, Document TM 0398 (Herbein dep., Exhibit 12).
30
Herbein dep. at 6.
31
Rogersdep. at 11-12.
32
Rogersdep., Exhibit 3111 at 6.
33
RogersInterview on May 4,1979 (IE) at 11.
34
KunderInterview on April 25,1979 (IE) at 22.
35
Miller Interview on May 7, 1979 (IE) at 44-46 (tapes
159 and 160) suggests that the PORV may have beenreported shut rather than the block valve since Miller
recalled the impression that the operators looked at a"demand light." Kunder first indicated that it was the block
valve, but in a later interview on May 17, 1979 (IE) at 33,
Rogers was not sure that it was the block valve.
Herbein's IE interview did not indicate which wasreported. If the report did involve the PORV rather thanthe block valve it could possibly have occurred before
6:18 a.m. However, we consider it more likely that theblock valve was reported shut as directly stated inKunder's and Roger's initial IE interviews.
36
G. P. Miller dep. (Sept. 20,1979) at 12-13.

229

26

NRC, "Investigation into the March 28, 1979 Three
Mile Island Accident by Office of Inspection and Enforcement," NUREG-0600, Section 4.6 at 1-4-28, August 1979.

27
Logan instructed Kunder to brief Miller. During thecall he was not aware that it was in progress. Afterwards
he asked if Kunder had briefed Miller. Ross and Mehler
were not aware of the call. The question has not been
specifically asked of the remaining control room personnel. However, none has mentioned any awareness in

85 5

55

Herbein Interview on May 10, 1979 OE) at 10, 16.
56
G. P. Miller Interview on May 7,1979 (IE) at 19-21.
57
Arnold Interview on May 9, 1979 (IE) at 10.
Arnold dep. at 8.
59
Arnold Interview on May 9, 1979 (IE) at 12-14.
60
Arnold dep. at 9.
81
Arnold Interview on May 9,1979 (IE) at 17.
62
Arnold dep. at 12.
63Arnold Interview on May 9, 1979 (IE) at 17-18.
64
Arnold dep. at 20.
65
Arnold Interview on May 9, 1979 (IE) at 20-21.
66
Keaton dep. at 13.
67
R. Wilson Interview Memo (Oct. 8, 1979) (not yet
signed) at 4.
68
Arnold dep. at 20-23.
69Id. at
5-6,12.
70
Herbein dep. at 43.
71
Herbein Interview on May 10, 1979 (IE) at 17-18.
72
Herbein dep. at 54.
73
Arnold dep. at 27-28.
74
R. Wilson Interview Memo (Oct. 8, 1979) (not yet
signed) at 6-7.
75
Arnold dep. at 26, 31, 33-34.
76
Vollmer dep. at 36.
77
Moore Interview on June 11, 1979 (IE) at 4, 5,12.
78
Nitti dep. at 4-5.
79
Moore Interview on June 11, 1979 (IE) at 12.
80
Faust, Frederick, Scheimann, and Zewe dep. at 11.

91

Faust, Frederick, Scheimann, and Zewe dep. at 26.
Hitz dep. at 20-22.
94
Pres. Com. Hearing (May 31, 1979) at 172.
95
FIoyd dep. at 29.
96
Hitz dep. at 26.
97
FIoyd dep. at 55.
98Id. at66-67.
99
Pres. Com. Hearing (May 31, 1979) at 178-179.
100
Floyd dep. at 92.
101
G. P. Miller dep. (Sept. 20, 1979) at 51-52.
102
Faust, Frederick, Scheimann, and Zewe dep. at 57.
103
FIoyd dep. at 90.
104Id. at
72-75.
105
Faust, Frederick, Scheimann, and Zewe dep. at30-31,
57-58.
106
Hitz dep. at 23.
1 7Id. at°
23-25.
108
Faust, Frederick, Scheimann, and Zewe dep. at 31.
93"Pennsylvania Emergency Management Agency Log,
Message 15, Time 8:40 a.m., dated March 30,1979.
110
FIoyd dep. at 84-85.
1nKeaten dep. at 84-86.
112
R. Wilson Interview Memo (Oct. 8, 1979) (not yet
signed) at 9.
113W. Lee Interview Memo (Dec. 21, 1979) (not yet
signed) at 3.
114
Dieckamp dep. at 35.
11b
Kunder dep. at 125-127.
116
Kunder dep. at 143-145 (Pres. Com.).
117"TMI Station, March 28, 1979 Event, Unit Two, G. P.
Miller, Station Manager," (Miller dep., Exhibit 114).
118
Hendrie dep. (Oct. 23, 1979) at 133-134.
119
Denton dep. (Oct. 23, 1979) at 25, 26, 36.
120
Case dep. at 75-76.
121
Grimes dep. at 249.
122
Eisenhut dep. at 209.
123
Hendrie dep. at 131-132.
124
Case dep. at 132-134.

81

Hitz dep. at 11.
14.
83
FIoyd dep. at 28.
4
B Faust, Frederick, Scheimann, and Zewe dep. at
22-23.
85
FIoyd dep. at 34.
86
Faust, Frederick, Scheimann, and Zewe dep. at 20.
87
Pres. Com. Hearing (May 31,1979) at 173, 178.
88
Faust, Frederick, Scheimann, and Zewe dep. at
26-27.
89
FIoyd dep. at 31.
82Id. at

90Id. atPres. Com. Hearing (May 31,1979) at 172-181.

92

125

30-33.

856

Eisenhut dep. at 205-206.

3. RADIOLOGICAL EMERGENCY RESPONSE
a. Introduction and Summary
The Metropolitan Edison Company activated theirradiological emergency plan to cope with a reactor
accident at Unit 2 of their Three Mile Island nuclear
powerplant near Middletown, Pa., on March 28,
1979 at 6:55 a.m. This plan was based on Federal
requirements for operators of nuclear powerplants,
and had been coordinated with the Commonwealthof Pennsylvania emergency plan. However, wefound that parts of TMI's written emergency plan did
not fully conform with all of the existing NRC guidance on such plans. NRC's staff had been awareof these differences for several months, but had not
notified Met Ed. Conceivably, some of these differences were shortcomings that had a negative impact on the response to the accident. However, thedeviations from NRC's guidance delayed rather thanprevented the desired response or action.
Coping with the effects of this reactor accident
was the first real test of Met Ed's radiological emergency plan. The Special Inquiry Group looked into
how well this plan worked to see what could be
l earned.
During the first day, the Met Ed emergency organization was frequently reorganized to adjust tochanging conditions. Lacking a strong and clearly
defined chain of command, individuals lost contact
with the organizational structure and took independent actions-some beneficial, some ill-advised.
Emergency procedures designed to guide theresponse were in some cases less effective thanthey should have been and in others were not followed.
With the exception of the TMI-2 control room
staff and those personnel in direct contact with thecontrol room, most Met Ed staff involved had only alimited understanding of what had happened or the
potential for more serious consequences. Still theycame to the plant early, stayed late, and worked diligently for many days in efforts designed to protect
the health and safety of the public. In this effort,
that portion of the plant staff responsible for collection and distribution of offsite exposure information
was reasonably effective.
Although the response of many individuals on theplant staff was commendable, there were problems
in such areas as recognition that an emergency exi sted, organization and the chain of command, andstaffing and timeliness of determining offsite radiation levels. These problems were influenced byshortcomings in the emergency plan and preparations. Frequent drills contributed to the ability of
85 7

plant personnel to implement the initial response to
the accident. Equipment provided for the preplanned communications to State and Federal agencies worked well and was adequate; however, as
more people and organizations got involved, thenormal telephone system quickly became overloaded. The early response was aided by the availabilityof a full day-shift crew, but plans were inadequate
for either an extended or augmented response. Radiation monitoring instrument limitations including
design, installation, operation, and availability, hampered the initial off site dose assessment calculations and the subsequent field monitoring response.
Improvements in these deficient areas are needed
to provide an acceptable emergency response capability on the part of Met Ed.
The majority of TMI staff who responded to theradiological emergency were not involved with control or mitigation of the inplant radiation levels or
releases of radioactive material. Their principal
tasks, with respect to offsite releases of radioactive
material, were to identify and assess potential offsite
exposures and to notify the State of their findings.
This enabled the State to take appropriate protective actions for the public. Officials of the Pennsylvania Bureau of Radiation Protection generally weresatisfied that Met Ed adhered to their commitment
to provide information and assistance. Margaret
Reilly, Chief of the Environmental Radiation Divisionof the Pennsylvania Bureau of Radiation Protection,
later said, "I really don't have any great complaints
with them [MetEd] I think they upheld their end of1
the bargain."b. Identification and Declaration of
Emergency
On March 27, at 11:00 p.m., the crew that was tooperate TMI-2 until 7:00 a.m. the next day beganwork. The operating crew included a shift supervisor, a shift foreman, two control room operators,
and six auxiliary operators. The radiation chemistry
technicians (rad chem tech) on that shift included
four technicians and one trainee. At 4:00 a.m. on
March 28, the turbine and then the reactor tripped
as a result of a loss of feedwater to the steam generators and the resulting primary system pressuretransient. The pressurizer pilot-operated relief valve(PORV) opened, as designed, but failed to close,causing a loss of cooling water from the reactor
coolant system into the reactor building. This constituted a small loss-of-coolant accident. The loss ofreactor coolant water resulted in a drop in pressurei n the reactor from 2435 to 1015 psig in about 20

minutes, and an increase of 1.4 psig in the reactor
building in 15 minutes.
Approximately 4:30 a.m., Terry Daugherty, an
auxiliary operator, saw that the reactor building
sump pumps were working and that a reactor buildi ng high sump alarm had been received. As he left
the area, Daugherty observed a visual alarm on a
nearby radiation detection instrument (RH-14/HP210), and reported the operation of the sump
pumps, the high sump alarm, and the radiation instrument alarm to Ed Frederick, a control room
operator. Daugherty was directed to make a radiation survey in the area of the radiation detection instrument. The survey indicated a radiation level ofless than one-tenth of a milliroentgen per hour
( mR/h), which was not much in excess of the radiation levels usually observed in the area.
Daugherty's observations concerning the sump
pumps and sump level alarm were reported to William Zewe, Shift Supervisor, who directed that thereactor building sump pumps be turned off because
he believed the receiving liquid waste storage tanks
were almost full. The reactor building sump pumps
were manually turned off at 4:38 a.m.
The criteria for declaration of a site emergency(TMI Emergency Procedure 1670.2) include "loss ofprimary coolant pressure, coincident with a highreactor building pressure and/or high reactor buildi ng sump level." One could have interpreted theconditions that existed at this time to conform tothis criteria. However, Zewe interpreted the conditions in a way that precluded the declaration of asite emergency. He believed that the reactor
coolant system pressure had stabilized, and that theincrease in reactor building pressure and the highreactor building sump level were not sufficient cause
to declare an emergency. 2 No site emergency was
declared.
As part of the normal post-trip procedure, Dave
Zeiter, a rad chem tech, collected a sample of Unit 2
primary coolant in the sample room located near the
Unit 1 radiation protection laboratory area about
5:00 a.m. The sample was analyzed for boron, anda significantly lower concentration was observed
than existed before the trip. Therefore, a second
sample was requested.
Also at that time, the Radiation Protection andChemistry Supervisor, Richard Dubiel, was called
and instructed to report to the plant. Between 5:00
and 5:20 a.m., three radiation alarms werereceived-the reactor building air particulate monitor
and two liquid process monitors near the reactor
building. Zewe did not recall the air particulatemonitor alarm; he was aware, however, of the twoprocess monitor alarms, which he attributed to a
crud burst (a release of deposited radioactive ma-

terial from , the internal surfaces of the reactor
coolant system). He also believed that the emergency procedures referred only to area radiation
monitors and not to process monitors when considering the requirements for the declaration of an emergency. The emergency plan identifies one of theconditions for declaration of a local emergency as
the point at which "more than 1 radiation monitor ina single building reaches their alarm setpoint," Procedure 1670.1, Local Emergency Procedure, on theother hand, describes one of the conditions for declaring an emergency as the point at which "one ormore radiation monitors in a single building reach
their high alarm setpoint. More than one radiation
monitor reaches the low alarm setpoint." Between
5:15 and 5:45 a.m., the levels indicated by certain
radiation monitors continued to increase and several
reached the preset alarm level. No local emergency
was declared.
Dubiel arrived on site at 5:40 a.m. and was asked
to change the charcoal cartridge and particulate
filter in the reactor building air monitor. He and Mike
Janouski, a rad chem tech, were unable to complete
the change when they found the sample line full ofwater, indicating a steam environment in the reactor
building.
Two more primary coolant samples were collected. The last sample, taken about 6:00 a.m., indicated a still lower boron concentration and a factor of
10 above normal concentrations of radioactive material. These concentrations had not been determined in the two earlier samples.
At 6:18 a.m. the PORV block valve was closed,
terminating the continued loss of reactor-coolingwater through this path. After closing the PORV
block valve, two area radiation monitors, a reactor
building air particulate monitor, and an incore panel
area monitor, reached their alarm setpoints (the air
particulate monitor for the second time). At 6:30
a.m. Dubiel was asked to arrange an entry into thereactor building; however, because of the impending
7:00 a.m. shift change and subsequent events, theentry was never attempted.
Between 6:30 and 7:00 a.m., several area andprocess radiation monitors alarmed because of increasing radiation levels. Radiation surveys were
performed by rad chem techs John Donnachie, Mike
Janouski, and Richard Brenner. Joe Deman, a Radiation Protection Foreman, directed the surveys in
the TMI-2 auxiliary building. Brenner detected levels in excess of the 5 R/h range of his survey instrument, while Donnachie and Janouski, using ahigher range instrument (teletector) measured 10
R/h at the doorway to the makeup tank room. Terry Daugherty and Dale Laudermilch, auxiliary operators, were also in the auxiliary building when, ac85 8

cording to Laudermilch, Daugherty observed, "Hey,we're getting water out of the floor drains... [the]3Shortlyaux building sump is overflowing."
thereafter, Janouski came running through the area3
and told them to "get the hell out." Janouski's actions were coincident with the declaration of a site
emergency by Zewe. Meanwhile, Juanita Gingrich,a former plant security guard who recently begantraining as an auxiliary operator, was working in theadjacent turbine building. Gingrich was manually rotating the "B" main feedpump turbine one-half turnevery 2 minutes. Later she explained, "I had tokeep doing that to keep the shaft fromwarping ... that was one you always have to do
everytime the turbine trips, cause they never got it
4[ motorized turning gear] fixed yet." When asked if
an evacuation of the turbine building was required
Gingrich acknowledged, "Yeah, shortly after thatthey gave the evacuation.... And then, after that,they told me I should stay down here." 4 Gingrichstayed until she was relieved at 8:00 a.m. in spite of
audible alarms from the atmospheric radiation moni5
tor located at the nearby condenser vacuum pump.
( Gingrich left the site around 10:00 a.m. after being
checked and found free of contamination.)
Approximately 6:40 a.m., a fourth primary coolant
sample was collected. The sample containedroughly 140 microcuries per milliliter (µCi/ml) of
gross gamma activity. This level of activity was approximately 350 times the normal level. Processsample lines, including reactor coolant sample lines
from Unit 2, run to the Unit 1 sample room. The Unit
2 sample lines were not shielded in Unit 1. Whenthe coolant sample was collected about 6:40 a.m.,the increased radiation levels from the primarycoolant in the sample lines caused area radiation
monitors to sound alarms in the Unit 1 sample roomand the nearby hot machine shop. Consequently,
the technician stopped recirculation of primarycoolant through the sample lines.
At 6:45 a.m. Dubiel instructed Mike Kuhn, a radchem tech, to call Tom Mulleavy, Radiation Protection Supervisor and Fred Huwe, a Radiation - Protection Foreman, and ask them to report to the plant.
When the alarm in the hot machine shop area monitor rang at 6:48 a.m., a survey showed radiation levels of 1.5 R/h on the sample lines and 500 mR/h in
the general area. Dubiel notified George Kunder,
the Unit 2 Superintendent of Technical Support,
who was in the control room, of the increasing radiation levels. Kunder later stated:

God we're failing fuel' and I yelled at Joe [Logan,
Unit 2 superintendent]. I said 'Joe, we're failing
fuel, Dick's got 600 mR/h at the sample lines,' andthat was right around 6:45 in that region and I said
' hey, we're into site emergency, it's the real thing,'
and a site emergency was declared. 6

Zewe said later:

I declared a site emergency because the radiation
l evels were going up, and it was getting worse andwe really didn't know at that time exactly where theactivity was coming from, and then we had a reportthat the aux[iliary] building drains were backing up
and that the water in the drains was the source ofthe radiation going out the station vent. All our radiation monitors in the building showed this....

Dubiel put Janouski in charge at the emergency
control station located in the Unit 1 radiation protection laboratory area, and then hurried to the Unit 2
control room as the site emergency alarm wassounded and announced. The site emergency was
declared at 6:55 a.m. based on the alarms of process and area monitors.
Gary Miller, the Station Manager, arrived andtook over as the emergency director, declaring ageneral emergency at 7:24 a.m. This declaration
was based on a reading in excess of 8 R/h on thereactor building containment dome monitor (HP-R214). The declaration was in keeping with the requirements of Procedure 1670.3, General Emergency Procedure. It should be noted that the HP-R-214
detector, an ion chamber, was shielded with enoughlead to reduce the instrument response by a factorof 100. The dome monitor reading increased 200fold between 7:13 and 7:18 a.m. before leveling off at
200 R/h, which was assumed to be indicative of adose rate of 20000 R/h in the reactor building.
During our review, we found that the TMI emergency plan, contrary to the guidance in Regulatory
Guide 1.101, had no Emergency Alert Class. Such aclassification is described as involving "specific situations that can be recognized as creating a hazard potential that was previously nonexistent or latent." 8 It is possible, that had such an emergency
classification existed in the TMI plan, an alert might
have been declared earlier. Nonetheless, information was available in the control room indicating thatthe plant conditions were degrading and the criteria
li sted in the emergency plan for the declaration of asite emergency were exceeded as early as 4:38
a.m.

Dick [Dubiel] called up very shortly thereafter and I
heard him screaming over the page 'George
Kunder, George Kunder, line one' and I answered.
Dick said, 'George, the sample line had just went up
to 600 mR/h,' and at that point I realized 'oh myc. Organization and Staffing
With the declaration of a site emergency, the Unit
2 control room staff began implementing Procedure859

1670.2, Site Emergency. The Unit 2 control room
became the emergency control center. The emergency procedures identify specific duties andresponsibilities with respect to certain organizational
positions and functional responsibilities. The procedures also specify alternates and require appropriate training for each identified position andresponsibility. Changing the operating organization
to one designed for emergency response disrupted
the normal chain of command and communication.
This change occurred as the regular day shift wasarriving for work. The emergency organization established following the announcement of a site emergency is shown in Figure 111-4.
" Plant Operations" continually assessed andcorrected plant conditions to establish or maintainstability and to mitigate the consequences of theaccident. The "Radiological Assessment" group assessed and estimated the accident's radiologicalconsequences. The "Emergency Control Station
Director" was responsible for the assembly and deployment of various onsite and offsite monitoring
teams, monitors, repair parties, and emergency
chemistry personnel. The "Accountability" groupcontrolled access to the site, assembled nonessential personnel, and accounted for personnel on site.
Although there was some confusion as to assignments, by the time Miller arrived at 7:05 a.m., thevarious groups had begun to function. Personnel
due for the 7:00 a.m. shift change were on site or
arrived shortly after the site emergency was announced. Miller informed the staff that he was assuming the role of Emergency Director, and he established a command team that reported to him. The
resulting organization differed in some respects
from the earlier one, as shown in Figure 111-5. As
Miller described the following:

Basically, I set up this emergency command team in
the early hours as I arrived at the plant and the radiation emergency was in progress, by essentiallyforming my senior people into a network to supervise, conduct the emergency, and report to me
while bringing the plant to a safe conditions

Dubiel later said that although this organization differed from the emergency plan, it was an organizational structure that had been included in drills.
Between 6:55 a.m. (when Dubiel instructed
Janouski to set up the emergency control station at
the Unit 1 radiation protection laboratory area) and
7:35 a.m. (when Mulleavy arrived and assumed hisrole as Emergency Control Station Director), there
was some confusion as to who was in charge. Radiation Protection Foreman Deman arrived at theplant before the site emergency was declared, andafter talking to Dubiel, entered the plant to makesurveys. After the emergency was declared Deman

quickly returned to what was now the emergency
control station. When Janouski saw Deman he assumed he was relieved and began to function as amember of a monitoring team. Pete Velez, another
Radiation Protection Foreman, arrived about 7:05
a.m. and worked with Deman in getting the onsite
and offsite monitoring teams started. Both men
then directed their attention to other activities.
Huwe arrived at 7:15 a.m., and believing that no one
was in charge of the emergency control station, assumed that responsibility until relieved by Mulleavy
about 7:35 a.m. Mulleavy remained as the Emergency Control Station Director until the next day.
The next organizational change occurred about
9:00 a.m. when increasing radiation levels and airborne radioactive materials caused personnel tomove the emergency control station to the Unit 2
control room. This revised organization is shown in
Figure 111-6. The loss of the radiation protection laboratory area facilities denied access to the only
operating multichannel gamma analyzer. With thel oss of this capability, Met Ed was no longer able toanalyze for iodine-131 in the presence of noble
gases. As a result, personnel in both units, including
those in the control rooms, were later required towear respirators when this might not have been otherwise required. The loss of this area denied access to radiation protection equipment and supplies,
and to the personnel decontamination showers andfacilities. The transfer of the emergency control
station to the Unit 2 control room went smoothly. It
was an evolution that had been included in one of
the emergency plan drills conducted in 1978.
As originally conceived, the repair parties operated out of the emergency control station and theiractivities were coordinated by the director of theemergency control station. This assured that radiological controls designed to limit personnel exposures would be followed and that maximum radiol ogical information would be gained from each entry
i nto a contaminated or radiation area. Under the organizations established prior to 8:00 a.m., repair
parties were established in both the Unit 2 control
room and emergency control station. By 8:00 a.m.
all repair party personnel had been relocated to theUnit 2 control room. After the emergency control
station was relocated, Dubiel and Mulleavy redistributed the radiological workload. Mulleavy retained
control of the on-and offsite monitoring teams; Dubiel assumed direct control of inplant radiation protection functions. As a result of this change, somel oss of control and information occurred that might
have been avoided under the initial organization.
Between 10:00 and 11:00 a.m., the emergency
control station was relocated to the Unit 1 control
room where it remained for an extended period.
860

FIGURE 111-4. Organization Described in Emergency PlanFIGURE 111-5. Emergency Organization in Effect on March 28, 1979,
7:30 a.m.-9:00 a.m.

ECC - EMERGENCY CONTROL CENTER - UNIT 2 CONTROL ROOM

AECS- ALTERNATE EMERGENCY CONTROL STATION . UNIT 2 CONTROL ROOM"

. FUNCTIONAL TITLE ADDEDFIGURE III-6. Emergency Organization in Effect on March 28, 1979,
9: 00 a.m.-11:00 a.m.

863

The emergency organization stabilized with thismove and continued without significant change. The
final organization is shown in Figure 111-7.
As a result of increasing radiation levels at theonsite assembly area, all nonessential personnel
were evacuated from the island at 11:10 a.m. Met Ed
deviated from the original concept of organizationand staffing laid out in the emergency plan. Thechange in reporting channels apparently left somepersonnel adrift and unfamiliar with the existing
chain of command.
Some rad chem techs stated that they reported
to any of the available radiation protection foremen.
Furthermore, some personnel assumed functions
that were not the best use of their abilities, e.g., twochemistry foremen worked as gate monitors, andtwo newly hired and untrained rad chem techs performed more complex duties at a monitoring anddecontamination station. However, the evidence
does not indicate that this matter made a significant
difference during the emergency response.
Miller continued as Emergency Director until
about 2:00 p.m. when he, Kunder, and Jack Herbein, Vice President of Generation, left the area tobrief Lt. Gov. Scranton in Harrisburg. Although Miller objected to leaving the plant, he did not feel thesafety of the public was jeopardized by his departure. 10 Miller returned to the plant at about 4:30
p.m. This absence by Miller appeared not to have
any impact on the execution of the radiological emergency plan. After his return, Miller continued as
Emergency Director until he left the site around 2
o'clock the following morning. Joe Logan, Unit 2
Superintendent, took over as Emergency Director
until Miller's return a few hours later. Logan reported to the Unit 2 control room at 5:45 a.m. on March
28, and did not leave until noon on March 29.
By the evening of March 28, many of the plantstaff were exhausted. Management was slow torecognize that the emergency wasn't going to end
conveniently like the drills. In the absence of planning for an extended response, management belatedly began setting up revised shift schedules andsending members of the staff home. Twelve-hour
shifts were planned, but some individuals worked forextended periods of 24 to 30 hours. In one case,
Ed Egenrider, a rad chem tech, worked 48 hours
without relief.
In the days following March 28, the emergency
response organization remained substantially unchanged. Shifts were established and personnel
were replaced. The emergency control centerremained in the Unit 2 control room where concerns
were mainly directed to stabilizing and cooling thereactor. None of the principals involved in the or-

ganization were able to state when the emergency
ended.
The emergency control station remained in the
Unit 1 control room from which the onsite and offsite
monitoring teams were directed. These monitoring
activities continued until the-first half of July; longafter onsite and offsite radiation levels had returned
to preaccident levels.
Emergency Director-Succession, March 28-29,
1979

Miller took over as Emergency Director when hearrived in the Unit 2 control room at 7:05 a.m. Herbein arrived at the TMI Observation Center around11:40 a.m., at which time he received a telephonebriefing on the plant's status from Miller. Herbein
was under increasing pressure from the Governor's
Office for information about the plant's status. 11,12
As a result, Miller said he was "directed [by Herbein) to go to the Lieutenant Governor's office, and,
therefore, I departed the site at approximately 1430
with as much information as I could about the incident."13 Satisfied that the plant was reasonably
stable, Miller left the control room around 2:00 p.m.
at which time Logan was placed in charge of theplant as Emergency Director. Logan's original assignment had been to assure that all actions required by procedures and the emergency plan wereaccomplished. Michael Ross, Unit 1 Supervisor ofOperations, was placed in charge of Unit 2 operations. Both Logan and Ross had been in the control
room since early morning.
James Seelinger, Unit 1 Superintendent, wascalled to the Unit 2 control room by Ross shortly
after Miller left the plant. Seelinger believed that
Ross wanted organizational support for the emergency plan activities, which Seelinger provided.
Seelinger remained in the Unit 2 control room until
Miller returned from the Lieutenant Governor's Office about 4:30 p.m. Seelinger then returned to theemergency control station in the Unit 1 control room.
When Miller returned he reassumed the position of
Emergency Director and remained in full command
until about 8:00 p.m., when, believing that senior
Met Ed management (Herbein) had taken overdirection of activities, he considered himself to be a
Shift Superintendent/Emergency Director. Miller recalled that on the night of the 28th he appointed
Seelinger as his alternate, an assignmentthat
14remained in effect for about a week. Seelinger andRoss recalled that the transition to shifts occurred
15,16
after they returned to the plant on March 29.
Herbein left the Observation Center and the immediate area between 1:30 and 2:00 a.m. 17 Seel864

FIGURE 111-7. Emergency Organization in Effect on March 28, 1979,
11:00 a.m.-8:00 p.m.

86 5

i nger returned to the Unit 2 control room between
9:00 and 10:00 p.m. Seelinger, Ross, and Miller
went to their homes about 3:00 a.m., and Kunderwent home sometime between 3:00 and 4:00
am15,16.18 The departure of these four men left Logan in charge as Shift Superintendent/Emergency
Director.
On March 29, a shift schedule was set up thatprovided for continuity in the Shift Superintendent/ Emergency Director position. Although theposition of emergency director remained in the organization, it became a less effective part of Met
Ed's response to the radiological emergency. The
shift superintendent/emergency director was increasingly concerned with inplant matters relating tocontrol and cooling of the reactor.
Continued operation of the makeup system was
required to ensure that the operating reactor
coolant pump would continue to force cooling of thedamaged reactor core on both the 28th and 29th.
Because of the buildup of gases in the makeup tankfrom outgassing of reactor coolant, the operators
periodically vented the makeup system to the waste
gas header in the auxiliary building. The evening of
the 29th, operators were aware that this process
was a major source of the radioactive gases thatwere released from the plant, and which were observed above the plant vent on both the 29th and30th. The high radiation level of 1200 mR/h measured above the plant vent at 8:01 a.m. on the 30th,
caused the evacuation scare later that day and contributed to the Governor's subsequent decision toadvise pregnant women and preschool children
within a 5-mile radius of the plant to leave the region, and to close the schools within that area.
We could find no evidence that the operator action of venting the makeup tank to the vent header
was discussed with, or approved by, the emergency
director. Moreover, the reason for the venting andthe control methods used during venting were notcommunicated to Met Ed, the NRC, or State officials
who were both surprised and alarmed by the highradiation levels above the plant on the 30th. On themorning of the 30th, there apparently was confusion
about who was in charge of plant operation. Zewe
testified that he and another supervisor, Greg Hitz,
made the decision and took the action to vent the
makeup tank. James Floyd, the Unit 2 Operations
Supervisor, has testified that he made the decision.
I n either case, apparently neither informed Logan,
who was functioning as the Emergency Director at
this time. Miller, who was outside of the plant buildi ngs in his office when the activities took place,came to the control room after the venting was in19
progress.

Emergency Control Station and Monitor Team
Evolution

When the emergency control station was relocated to the Unit 1 control room between 10:00 and
11:00 a.m. on March 28, Mulleavy was the Director.
Under his direction the dose assessment calculations, which began earlier in the Unit 2 control room,and the on - and offsite monitoring activities, whichwere controlled from the emergency control station,
were continued. Mulleavy left the plant about 3:00
a.m. on March 29, and was replaced by WilliamPotts, the Unit 1 Superintendent of Technical Support.
Mulleavy returned to the emergency control station on Wednesday afternooon or evening and rotated with Potts until he was relieved by Alexis
Tsaggaris, Station Maintenance Supervisor fromMet Ed's fossil fueled powerplant at Reading, Pa.
Tsaggaris, prior to his assignment at Reading,
had been training supervisor at TMI and was closely
i nvolved in emergency plan training. Potts andTsaggaris rotated as directors of the emergency
control station. During the postaccident period theemergency control station had engineers who performed dose assessment calculations, as well as
health physics and environmental specialists who
directed the monitoring teams and interpreted thedata. A consultant, Sydney Porter of Porter-Gertz,
worked in the emergency control station after he arrived on the evening of March 28. Porter had assisted in the preparation of the TMI emergency procedures and some of the drill scenarios.
Fatigue of the monitoring teams and the necessity for maintaining and expanding the followup resulted in the decision to use non-TMI radiation protection technicians in this effort. By midnight on the
28th, support was arriving from sister utilities. According to the visitor registration log, the first personnel were from the Salem plant of the Public Service Electric and Gas Company of New Jersey.
They were followed by personnel from theSusquehanna plant of the Pennsylvania Power andLight Company. Included in the latter group was
William Allen, Dubiel's counterpart who was put towork in the emergency control station. Philadelphia
Electric Company personnel arrived on March 30.
Fourteen technicians (rad techs) from Nuclear
Support Services Inc. (a firm that supplies contract
radiation protection services to the industry) arrived
at TMI on the 29th, four arrived on the 30th, andfive on the 31st. Most were used as offsite monitors
enabling the Met Ed rad chem techs to return to TMI
to perform inplant monitoring activities. Monitoring
teams were staffed and manning schedules
86 6

developed at the Observation Center command post
on March 29. The three monitoring teams available
on the 28th were expanded to five on the 29th, andsix on the 30th. A seventh team was later established for a short period.

Two crews totaling eight individuals were off duty.
Donnachie, a member of one of the two offduty shift
crews, was working an overtime shift when the accident occurred. Three of the seven remaining off
duty rad chem techs, reported or attempted to report to the site early when they learned of the accident. The evidence indicates that personnel fulfilled their obligation for protection of the public tothe best of their abilities.

Corporate Response-Development

Early in the morning of the 29th, a command post
and long range planning and logistical unit was established at the Observation Center by senior Met Ed
and General Public Utilities (GPU) personnel. Thesei ndividuals had no assigned role in the TMI emergency response, however. The buildup of support
by Met Ed and GPU was significantly aided by thefact that utilities customarily respond to disaster or
accident-caused service disruptions.

d. Dose Assessment and Onsite and Offsite
Monitoring
With the announcement of a site emergency, Howard Crawford, a nuclear engineer, reported to theUnit 2 control room to perform onsite and offsite radiation dose assessment calculations. Shortly after
7:00 a.m. Crawford examined the two radiation
monitors of greatest significance-HP-R-214, thereactor building dome monitor (gamma); and HP-R219, the station vent monitor (particulate, iodine, andgas). He found that the most significant value wasdisplayed by HP-R-214, which he then used as thebasis for his initial calculations. According to Crawford, the meter reading was 300 R/h for the dome
monitor at that time.
Procedure 1670.4, Radiological Dose Calculations, is one of the implementing procedures of theemergency plan; its purpose is to obtain early information for the decisions necessary to limit the
public's exposure during a nuclear accident. Using
this procedure, dose rates at offsite locations were
estimated based on measured or potential airborne
releases from the plant and prevailing meteorological conditions.
The evidence suggests that the initial calculation(completed shortly after 7:18 a.m.) estimated a radiation dose rate due to noble gases of 10 R/h inGoldsboro. Plant personnel considered this estimate to be abnormally high because the pressure in
the reactor building was less than that assumed forthe calculation. The calculation was based on thedesign basis reactor building leak rate of 0.2 weightpercent per day of the contained volume at a reactor building pressure of 56 psig. At the time, the actual reactor building pressure was 2 to 2-'h psig.
The estimate, however, was communicated at 7:35
am. to the Pennsylvania Bureau of Radiation Protection, which alerted the Pennsylvania Emergency
Management Agency authorities for possible evacuation of nearby Goldsboro and Brunner Island. By
7:45 a.m. the results of an onsite survey made at alocation between the plant and the community ofGoldsboro revealed that the radiation dose rate was

Response of Plant Personnel

A general comment by members of the plant staff
was that there was no panic and that the emergency plan went well. Not unexpectedly, the Unit 2
control room became crowded on many occasions;some estimates were that as many as 40 to 50 persons were in the control room at various times.
Miller said, "I spent many periods clearing the Conatmospheretrol Room in order to maintain the calm
2that was evident throughout the day." oSome of the events of March 28, belie the beliefof the staff. In certain cases individuals were instructed to carry out assignments involving significant potential exposures when appropriate radiation
detection instruments were not available and when
the task was unnecessary. Some of these instructions apparently were given without regard to acceptable radiation protection practices or adequate
knowledge of plant conditions. The problems encountered in implementing inplant radiation protection controls are discussed in detail elsewhere inthis report. When the emergency control station
could not be occupied because of increasing radiation levels or airborne radioactive material, it was
moved to the alternate emergency control station in
the Unit 2 control room. The move began at 9:12
a.m. and was completed by 9:17 a.m. Plant personnel involved in the relocation said it went well because it had been one of the scenarios practiced ina previous drill.
The staff responded to the accident with the
dedication and concern warranted by the situation.
The plant's radiation protection staff consisted offour radiation protection foremen, the chemistry
foremen, and four 4-man rad chem tech crews who
were on duty or reported for duty about 7:00 a.m.
867

l ess than 0.001 R/h (1 mR/h). Hence, the 10 R/hestimated dose rate at Goldsboro could not exist,
and the evacuation alert was canceled by thePennsylvania Bureau of Radiation Protection at 8:15
a.m. Subsequently, radiation surveys at Goldsboro
at 8:32 a.m. also showed that dose rates were lessthan 1 mR/h. (Details about the actions taken by
the plant staff with respect to the initial calculation
are provided elsewhere in this section of the report.)
Onsite and offsite radiation monitoring teams
were assembled and dispatched from the emergency control station after the declaration of the site
emergency. The teams normally consisted of two
rad chem techs designated by the emergency control station director. The teams took walkie-talkies
and picked up prepackaged emergency monitoringkits at the process center (Security Search Facility)
at the north end of Unit 1. Before leaving the process center, the teams inventoried the kit contents
to verify that the instruments would work. The
teams were then directed from the emergency control station to locations marked on maps contained
i n each kit. The activities of the on and offsite monitoring teams are known principally from the emergency control center-emergency control station log
of communications. The initial teams sent out were
given names of "Alpha," "Bravo," and "Charlie."
Personnel evaluating exposure data found thatvery few of the dose rate measurements made by
the teams on March 28 distinguished between open
(beta-gamma) and closed (gamma) window instrument readings, or identified the instruments used by
the teams. This oversight created problems in thesubsequent attempts to confirm data used for popul ation exposure calculations.
The Alpha team was dispatched at 7:25 a.m. toan area on Three Mile Island almost directly west of
the Unit 2 plant vent to make dose rate measurements and collect iodine samples. At 7:46 a.m., adose rate of less than 1 mR/h was reported at thatl ocation by the team. At 7:57 a.m., a second survey
team reported a dose rate of less than 1 mR/h at
the Observation Center east of the Unit 2 plant vent.
At 8:02 a.m. offsite team Charlie was directed to location W-11 in Goldsboro. At 8:10 a.m. a report ofless than 1 mR/h in Royalton, north of the plant, wasreceived from team Charlie on the way toGoldsboro. Team Bravo was initially dispatched tothe area east of the plant and later joined teamCharlie at Goldsboro.
On the morning of the accident the wind was
blowing very lightly (2-4 miles per hour) out of theeast toward Goldsboro. Goldsboro is only 1.4 miles
from the plant but is across the river and is noteasily accessible. For the offsite team to reachGoldsboro, it was necessary to drive a distance of

20 to 30 miles. The first recorded measurementfrom Goldsboro was at 8:32 a.m., about 1 hour after
the initial dose rate calculation. (During the sevenemergency plan drills conducted during 1978, an
offsite monitoring team was never required to travelto the west shore of the Susquehanna River.)The first reports received from Goldsboro werethat less than 1 mR/h was detected and that an air
sample was being collected. At 9:00 a.m., reports
were received from all three teams in the field (Alpha on site, Bravo and Charlie in the Goldsboroarea) that dose rates were less than 1 mR/h. The
results of analyses of air samples for iodine-131 coll ected in Goldsboro and on site were near theminimum detectable level. The observed radiationand iodine-131 levels were substantially below thel evels predicted by the early dose assessment calaculations. Team Alpha began to observe increasing
dose rates of up to 3 mR/h in the TMI north parking
lot about 10:30 a.m. The levels on site continued toi ncrease for 12 to 13 hours, with peak readings onsite of 365 beta-gamma/50 gamma mR/h.
The Pa. State Police supplied helicopters on
March 28 at the request of the plant staff. Trooper
E. Frantz, PSP Aviation Unit, flew a monitoring teamover Royalton, Middletown, Highspire, Goldsboro,
the Susquehanna River, and Unit 2 between 12:30
and 1:30 p.m. This was the only Met Ed aerial monitoring flight on March 28. (Other aerial surveys
were made by Federal agencies on the 28th.) At
1:30 p.m., dose rates of 10 and 20 mR/h were
measured above the Unit 1 cooling tower and Unit 2
reactor building. The emergency control station log
records the measurements on this flight as "300 ft
above Unit 2 Rx Bldg."
Land grade at Unit 2 is 304 feet above sea level,
and the top of the Unit 2 building and plant vent are
473 and 463 feet, respectively, above sea level.
Confusion in reporting altitude or elevation above
sea level or surface features was a continual probl em.
Measured offsite radiation levels on March 28
generally remained below background levels except
for a reading of 50 mR/h at 3:48 p.m. on the roadeast of Unit 2 near the Observation Center.
Between 10:30 and 11:00 p.m., levels of 13 and 12
mR/h were measured at the Kunkel School (5.6
miles NNW) and across the river from Olmstead(approximately 3.5 miles WNW). From 5:00 p.m. to
midnight, the wind was blowing at 5 to 15 miles perhour toward the northwest. However, Met Ed did
not make field measurements in this area until themeasurement at Kunkel School.
Met Ed analyzed onsite and offsite air samples
for iodine-131 using the Eberline SAM-2/RD-19 instruments. This equipment had a minimum detect86 8

stantially during this period. On March 28, thehighest onsite level measure at a predetermined
monitoring location was 365 beta-gamma/50 gamma mR/h. This level was not reached again; however, dose rates up to 150 beta-gamma/100 gamma
mR/h and 150 beta-gamma/30 gamma mR/h were
measured on March 29 and 31, respectively. Most
measurements during this period were in the rangeof 5 to 70 beta-gamma mR/h.
The highest level at a predetermined offsite monitoring location was 50 mR/h (whether beta-gamma
or beta is not recorded) on March 28. On March
29, the highest value was 30 beta-gamma/20 gamma mR/h with values generally falling to a few
mR/h. On March 30, the highest offsite level was
10 beta-gamma/0.4 gamma mR/h. The highest
value on March 31 was 12 beta-gamma/3 gamma
mR/h across the river from the plant at the 500-kV
substation. Many helicopter measurements, including those over the plant, plume definition measurements, and others at various locations over thecountryside, were made during this period. These
measurements were difficult to assess because
they were made at altitudes of 600 to 1400 feetabove sea level and ground level locations are notalways clearly fixed relative to the aerial measurements.
The use of helicopters permitted verification ofassessment calculations and provided a better basis
for source term calculations than would have been
available from ground level measurements. The
number of monitoring teams provided greater assurance that significant offsite exposure levels werei dentified.
On April 1, the number of monitoring teams was
reduced from seven to six. During the day, dose
rates on Three Mile Island ranged up to 40 betagamma/20 gamma mR/h, with values usually in therange of 2-12 beta-gamma/0.5-1.5 gamma mR/h.
Helicopter measurements went as high as 30 betagamma/5 gamma mR/h. Off site, the highest
readings-7.5 beta-gamma/1.6 gamma mR/hwere seen at the Observation Center and more distant areas usually measured less than 1 betagamma mR/h.
The radiation levels on Monday, April 2, continued to fall. The high levels on the island were 15
beta-gamma/7 gamma mR/h with most readings
less than 5 beta-gamma/1 gamma mR/h. The
highest offsite reading was 1.6 beta-gamma/0.1
gamma mR/h with most readings less than 0.5
beta-gamma/0.1 gamma mR/h. Between 2:25 and2:50 p.m., a gaseous release ranging from 90 to
400 beta-gamma mR/h was measured from a helicopter over the island. For most of the day, however, levels were in the range of a few to 15 beta-

able activity (MDA) for iodine-131 of approximately
5E-9 (µCi/cc) based on the volume sampled andbackground levels. Additionally, some samples
were analyzed by offsite support laboratories using
GeLi (lithium drifted germanium detector) spectrometer systems. A total of 27 samples were collected
and analyzed prior to midnight on the 28th. Reported onsite concentrations (SAM-2) ranged from lessthan the MDA to 6.8 E-7 µCi/cc iodine-131. Reported offsite levels (SAM-2) ranged from less than
MDA concentrations to 9.5 E-7 µCi/cc. Samples
that were counted using GeLi systems identified thepresence of noble gases, but iodine-131 was below
the MDA of these systems, which are more accurate and more sensitive than the SAM-2 instruments.
After the initial efforts on March 28, the emergency control station staff continued dose asessment
activities and established source terms principally
based on field radiation measurements by the monitoring teams. When helicopters became available
on March 29 and 30, readings in the plume-the invisible elongated cloud of radioactive gas extending
down wind from the plant-were also used forsource term calculations. As new field measurements became available, the source term data wascorrected using the True Source Term calculation
method. The use of this technique was necessary
because much of the Unit 2 monitoring instrumentation was off scale or, as in the case of the dome
monitor, resulted in unrealistic source terms. (Thiswas because the dome monitor measured the radiation levels in the reactor building and not in a
release pathway.) In the case of the plant ventmonitor, the data, when available (i.e., monitor not
off scale), was unreliable because of the very highbackground levels in the plant. When release of noble gases was detected in the Unit 1 plant vent, thesource term calculation described in the procedures
was used.
To make measurements establishing plume widthand dose rates, monitoring teams were directed tolocations where the plume was expected, on thebasis of meteorological information, as a means ofverifying the predicted dose rates. These methodsof offsite dose assessment were continued until the
Unit 2 plant vent monitor became more reliable.
The on- and offsite teams increased to seven on
March 30 and continued monitoring activities on a
24-hour basis. The teams recorded the results ofmeasurements, but were not instructed to maintainpermanent records. When data was reported to theemergency control station, the team survey records
were not retained and transmission errors could not
be identified or corrected. The number of groundlevel surveys on and off the island increased sub86 9

gamma mR/h. The number of monitoring teams on
April 2 were reduced to five.
I n later days on- and offsite dose rates continued
to fall. The teams, reduced to four on April 3, werestill on shift 10 days later. On April 8, all readings
were less than 1 mR/h. On April 9, the high readi ngs were 1.9 beta-gamma on the island, 0.43 betagamma/0.2 gamma in the air, and 2 betagamma/0.7 gamma off the island (all readings inmR/h). By April 13, most reports were less than 0.1
beta-gamma/0.1 gamma mR/h on TMI and less than
0.01 beta-gamma/0.01 gamma mR/h off TMI.
Although the emergency response phase waswinding down, monitoring activities continued. The
onsite and offsite monitoring team activities were
not terminated until the first half of July. Although
air samples have not been discussed in detail, samples were collected. After the arrival of the NRC
mobile laboratory on the evening of March 28 andthe subsequent arrival of other mobile laboratories,
the use of the SAM-2 instruments in the field essentially stopped. The increased sensitivity and resolution of the laboratory equipment made the SAM-2s
superfluous.

Each Radiation Emergency Kit contained a PIC6A (ion chamber survey instrument with ranges of
1-1000 mR and 5R/h); a SAM-2/RD-19 (battery
operated Stabilized Assay Meter and detector); an
air sampler; and maps, procedures, paper, pencil,
sample collection, and retention equipment. A
DC/AC inverter is used for operation of the air
sampler. Normally, the four monitoring kits and thei nstruments are inventoried and checked quarterly.
The kits are usually stored in the process center( North Search Facility). On March 28, however,
only three kits were in the process center; thefourth kit was in the radiation protection
supervisor's office because the SAM-2 was inoperable and had been since March 11, 1979. The SAM2s contained in the kits were the only instruments ofthat type at the Three Mile Island Station. When thethree available kits were checked on March 28, oneof the SAM-2s was inoperable. The operability of
the inverters was not checked, and so the first teamto arrive in Goldsboro that morning had both an
i noperable SAM-2 and inverter.
For the initial onsite and offsite monitoring effort,
the principal survey instrument was the PIC-6A.
From a total plant inventory of 14 PIC-6As, only thefour in the emergency kits were available for use on
March 28. As the need for additional radiation surveys increased, the available lower range RO-2 instruments (ion chamber with ranges up to 1 R/h)were placed in service. These instruments apparently performed adequately in the field.
The principal difficulty in performing field measurements involved measuring radioiodine. The accident had released significant quanitities of gaseous radioactive material, presumably including radioactive iodine. Met Ed had prepared for this possibility by including the SAM-2 (a battery powered
dual channel gamma analyzer with a gamma scintillation detector capable of controlling the high voltage and limiting instrument drift) in the emergency
kits. As designed, the instrument permitted independent counting of two channels or, if desired,subtraction of one channel from the other. As
operated by Met Ed's rad chem techs only one
channel was used, the other was held in reserve(not operating). During the accident the SAM2/RD-19 was not effective in measuring radioactivei odine in the presence of noble gases. The result
was that as noble gas concentrations rose so did
the apparent iodine concentrations, but in reality radioiodine concentrations were not a significant
problem.
The loss of the onsite laboratory counting facilities early on March 28 compounded the problem,
which was not resolved until samples were taken bye. Equipment Availability and Limitations
The ability of a nuclear powerplant's staff torespond to a radiological emergency is governed toa large extent by the ability to identify, measure, andquantify radiation levels and releases of radioactive
materials. These activities are made possible byfixed process, effluent and area radiation monitors,
fixed or semiportable inplant air monitors, and portable radiation survey instruments of various types.
For measurements outside the plant buildings, portable survey instruments and air sampling andanalysis equipment are required. The availability,use, and limitations of the portable and fixed inplant
equipment is addressed elsewhere in this report.
This section is limited to that equipment which theplant staff specifically designated for emergency
use outside of the plant.
TMI Procedure 1670.12, Emergency Readiness
Check List, identifies the numbers and types of emergency kits that are to be available as:
4
2
1
1
2
1

Radiation Emergency Kits
Wash Down Area Kits
Ambulance Kit
Emergency Clothing Kit
Control Room Emergency Kits
Medical Emergency Kit
87 0

telephones were used for communications between
the plant and State and local agencies.
After the site emergency was declared at 6:55
a.m. on March 28, two plant engineers, Ronald Warren and Richard Bensel, began making the notification calls. Separate notifications were required forboth the site and general emergency declarations.
This sequence and timing is shown in Table III-1.
The planned notification sequence was for PEMA
to receive notifications from the plant and in turn tonotify the Pennsylvania Bureau of Radiation Protection, who then contacted the plant directly. The
Bureau of Radiation Protection had difficulty returni ng the call to Unit 2. However, contact was obtained after a 3-minute delay and open telephoneli nes were established between the Bureau of Radiation Protection at Harrisburg and the Unit 2 control
room at 7:25 a.m.; and between the Unit 2 control
room and the NRC regional office near Philadelphia
by 7:50 a.m.
The TMI telephone system on March 28 included
a total of 14 two-way trunk lines (permitting calls either in or out) with more than 200 extensions, and 4
one-way trunks (one direction call only). Thirteen
business lines (like normal residential service) werealso available. By March 31, 21 business lines had
been added. At the Observation Center on March
28 there was only one telephone, but by March 30,
eight additional telephones had been installed. During the first week of April, approximately 40 more
telephones were installed at TMI.
Radio communications, consisting of portable radios and walkie-talkies, were installed in the Observation Center permitting the accumulation of datafrom the on-and offsite monitoring teams. A log ofactivities and communications at the Observation
Center was started at 8:15 a.m. on the 29th. Thel og was a minute-by-minute account of radiation
readings, air sample results, personnel cleared tothe site, reports of passing trains, requests for State
Police assistance for traffic accidents, and locationsof offduty personnel.
A second radio used for communications with theUnit 2 control room, offsite vehicles, and helicopters,
was set up in the Observation Center within about
24 hours. Additional radios were ordered and received during the first week of April.
After the accident there was a constant flow ofmonitoring data over the open telephone line to the
Bureau of Radiation Protection. From March 29 to
31, monitoring activities by non-Met Ed groups increased substantially, principally as a result of the
U.S. Department of Energy monitoring activities.
However, the flow of offsite monitoring information
was almost always from Met Ed to others. Essen-helicopter to the Bureau of Radiation Protection foranalysis later on the 28th. Subsequent analysis of
air samples using more sophisticated equipment established that no significant levels of radioiodine
were found off site.
f. Transportation
Met Ed's emergency plan specifies that, "At least
two vehicles can be quickly equipped ... for offsite
monitoring." 21 On March 28, when Ed Egenrider
and Thomas Leach were assigned to the first offsite
survey teams, no Met Ed vehicles were immediately
available. Egenrider finally commandeered a Met Ed
vehicle after a 10-minute search, and Leach took his
personal vehicle. Leach and Jim Randisi, teamCharlie, arrived in Goldsboro about 8:30 a.m.
When the initial telephone notifications of offsite
agencies were being made, Met Ed requested a helicopter to assist in transporting a monitoring team toGoldsboro. (The request was made at 7:17 a.m.)
The helicopter arrived at the TMI north parking lot at
8:35 a.m., too late to transport the monitoring team.
Met Ed had discussed the possible use of helicopters in the event of an emergency, but had notformalized arrangements with the Pa. State Police.
The police responded to the first request for ahelicopter and during the day, two helicopters were
either on site or at the Observation Center. On
March 28, these helicopters transported air sample
supplies to monitoring teams, and air samples fromthe Goldsboro area to the Holy Spirit Hospital for
analysis by the Bureau of Radiation Protection. The
helicopters were also used to wam boats awayfrom the vicinity of the island.
g. Communications and Notifications
The communications equipment available to TMI
staff on March 28 included the plant radiation emergency alarm system, the public address and telephone systems, the Met Ed tie line, Pennsylvania
Bell dial telephone equipment, and battery powered
telephones. Radio equipment included the Met Ed
system radio; FM walkie-talkie radios; Dauphin
County radio monitor; and the National Warning
System (NAWAS), connected directly to thePennsylvania Emergency Operations Center andState Police headquarters. On March 28, all ofthese systems were operational with the exceptionof the Dauphin County radio monitor, a frequency
scanner. The monitor's unavailability had no impact
on the course of the emergency response because
87 1

TABLE 111-1. Sequence and timing of site and general emergency declarations
Site Emergency
Declared 6:55 a.m.

General Emergency
Declared 7:24 a.m.

Duty Officer

7:02 a.m.

7:35 a.m.

NRC-Region I, King ofPrussia, PA

Answering Service

7:04 a.m.

7:40 a.m.

7:05 a.m.

7:40 a.m.

Met Ed, Manager,
Generation Operations

Mgr., Generation
Engineering

7:09 a.m.

7:30 a.m.

Duty Officer

7:09 a.m.

7:30 a.m.

U.S. Department ofEnergy-Radiological
Assistance Program

Duty Officer

7:09 a.m.

7:35 a.m.

No Answer
Philadelphia Electric
Load Dispatcher

7:13 a.m.

Dispatcher

7:18 a.m.

7:40 a.m.

No Answer

7:20 a.m.

7:35 a.m.

Agency Called
Pennsylvania Emergency
Management Agency( PEMA)

Met Ed Vice President(J. Herbein)

Dauphin County Civil
DefenseRadiation Management
Corp. (Consultant)Pennsylvania State
PoliceAmerican Nuclear
I nsurers

Person Contacted

7:40 a.m.

Herbein was in Philadelphia, unknown to the person making the call He had been in contact with Miller earlier
and could not be reached at the telephone listed in the procedures.

tially no monitoring information developed by others
was given to Met Ed's emergency control station or
to the Observation Center. The NRC regional groupresponding to the accident on the 28th did makesurvey measurements that were reported to theemergency control station.
Regarding Met Ed's commitment to provide information to the Bureau of Radiation Protection, Margaret Reilly, Chief, Division of Environmental Radiation, said during an interview:

cident, those agreements had in fact been met by
the licensee [Met Ed]?
REILLY: Correct

Communications with the monitoring teams were almost exclusively by radio. Radio dead spots
caused by terrain features presented problems, butthere were no requirements and no particular stress
was placed on this potential problem by the NRC.

Q: Did you have any difficulties in the area of communications, them [TMI] not providing informationthat was requested? Any at alI?

h. Augmentation

Q: Then, from your viewpoint and the agreementsthat had been reached during the course of the in-

Approximately 8:00 a.m. on March 28, Sydney
Porter, Porter-Gertz Consultants, Inc., received acall from M. Buring, a Met Ed corporate technicalanalyst, requesting Porter to set up and be ready toi mplement the expanded Radiological Environmental
Monitoring Program (REMP). Porter arrived at TMIREILLY: Not to my knowledge. We had sort of ageneric communication problem, being so dependent on telephones. We perceived that before theaccident, but all alternatives cost scratch, which I
think we'll probably be getting now.

87 2

at 8:25 p.m. and the first samples under the REMP
were collected on March 29.
As word of the accident spread, various types ofassistance and offers of asssistance were received.
Technicians and radiation protection and monitoring
equipment were supplied by many utility companies.
The first arrivals were from the Salem, Susquehanna, Peach Bottom, and Oyster Creek nuclear
powerplants. Similarly, technicians and equipment
were received from the suppliers to the nuclear industry.
Because of the high airborne activity levels, theplant staff rapidly depleted the supply of air bottles
for self-contained breathing apparatus. At 8:35 a.m.
on March 29, the local fire company arrived at theObservation Center to fill air bottles, an action which
was repeated several times on subsequent days.
Mobile laboratory facilities and whole-bodycounters arriving during this period included facilities
operated by the NRC and contractors. The availability of GeLi counting systems near the site permitted more rapid evaluation of air samples, a capability Met Ed lost early on March 28. The first mobilelaboratory to arrive (March 28, 7:30 p.m.) was
operated by NRC personnel.
On March 28, helicopter support had been provided by the Pa. State Police. Met Ed arranged forhelicopters on March 29, and eventually a total ofthree arrived, which were used for surveys and formoving equipment and samples.
At noon on the 29th, food was sent to the Observation Center for the operating crews. As thenumber of Met Ed and support personnel increased,
availability of food became a problem. This was
resolved by the establishment of a daily 24-hour
mess tent. The influx of personnel was staggering.
The initial onsite staff of about 530 increased bymore than 1900 persons by April 17. This increasei ncluded approximately 240 staff from GPU and its
subsidiaries, 200 from the NRC, and 1500 others.

site/Observation Center area around 2:00 a.m.
leaving Logan in charge. At the same time, organizational changes were made to support an expanded long-term followup effort. There was no opportunity for a substantial reentry or recovery phase to
begin because of the demands for continued on- andoffsite monitoring by the available staff.
On March 30 and 31, the arrival of support fromother utilities and nuclear support service groups
permitted the Met Ed radiation protection staff tobegin concentrating its resources for onsite activities. The Met Ed rad chem techs were then removed from the offsite monitoring teams. Later,
contractor radiation technicians familiar with theplant from their earlier refueling activities, began replacing Met Ed rad chem techs in Unit 1. One Met
Ed representative provided coordination between
the two radiation protection groups. By early April,although the reactor was stable and being cooled,
the accident, from a radiological standpoint, was notover. Releases were continuing and the response
phase was still in progress. There was no definite
point in time when the response changed to reentry
or recovery.
The reentry and recovery phases were in progress, attempting to minimize releases while the emergency control station and monitoring teams werestill in the response phase. The fact that a clearcut
definition of the current action phase was missing
made little or no difference. TMI Procedure 1670.15,
Post Accident Re-entry and Recovery Plan, iscorrect in its stipulation that:

A recovery plan, from a practical standpoint, must
be flexible enough to adapt to existing, rather thantheoretical conditions. It is not possible to anticipate in advance all the conditions that may be encountered in an emergency situation; therefore, theThree Mile Island Recovery Plan is addressed togeneral principles that will serve as a guide fordeveloping a flexible plan of action.

j. Summary of Findings and Recommendations

i. Response vs. Reentry vs. Recovery vs.
Emergency Termination

Findings• Declaration of a site emergency was delayed ap-

Miller said that his concern for plant stability was
substantially reduced, and a change from emergency response to a recovery phase occurred about
8:00 p.m. on March 28, when a reactor coolant
pump was started. At this time some confusion occurred between Miller and Herbein; Miller has testified that he thought Herbein became the focal point
for decisions regarding the overall emergency
response, exclusive of plant operation-Herbein
stated that Miller remained in charge. Both left theproximately 2 hours because plant personnel did
not understand that a loss-of-coolant accident
was in progress.
• Measurements of onsite and offsite radiationdose rates were not accomplished in a timely
manner considering the extraordinarily high esti mated offsite dose rate of 10 R/h.
• I nitial onsite and offsite monitoring teams had neither the equipment nor expertise to perform time87 3

•
•

•

•
•
•
•
•
•

ly measurements of airborne radioiodine in thepresence of radioactive noble gases.
The supply of operable radiation monitoring
equipment was inadequate to support the early
response of onsite and offsite radiation monitori ng teams.
I nitial calculations of onsite and offsite radiationdose rates (10 R/h) grossly overestimated theactual dose rate of less than 0.001 R/h. Unreali stic assumptions in the calculations resulted fromli mitations in the capability to monitor radioactive
gaseous effluents from plant buildings.
Absence of a clear chain of command in the emergency organization and the lack of a disciplined
approach in the communication of information toState and Federal agencies led to the evacuation
scare on March 30.
Organization and staffing for the prolonged
response to a radiological emergency had notbeen preplanned and was accomplished belatedl y.
Plant personnel carried out their assigned duties,
stayed on the job, and worked diligently toachieve a safe shutdown of the reactor and tocollect and distribute offsite dose information.
Communication systems available at the onset ofthe accident were adequate for initial notifications, but were not adequate to support the expanded response that developed.
Radio communications with offsite monitoring
teams were limited by the range of the equipment
and interference caused by the surrounding terrain.
Pennsylvania Bureau of Radiation Protection personnel in contact with the plant staff believe that
Met Ed provided the information and assistancecalled for by the emergency plan.
The emergency plan was activated under ideal
conditions, i - e., 2 hours advance warning tooperating personnel, a slowly developing accident, good weather, absence of equipment
damage or natural disaster, the start of a regular
work day, State and Federal agencies were nearby, plant personnel had participated in several recently conducted accident drills, and initial radioactive material releases from the plant wereminimal.

. The relocation of the emergency control stationfrom Unit-1 to the Unit-2 control room wentsmoothly because it had been practiced during
an emergency plan drill.
Recommendations• Plant procedures and personnel training require-ments related to radiological emergency recognition and response should be reviewed at all nuclear powerplants and upgraded to ensure that
operating personnel can recognize abnormal
conditions and initiate emergency response plansi n a timely manner.
• Real-time, online radiation monitoring equipment
should be installed around all nuclear powerplants. This equipment should be capable ofmeasuring radioactive materials that may bereleased during reactor accidents, and use of thisi nformation should be included in emergency
planning.
• I nplant and portable radiation monitoring instruments and trained personnel should be available
at all nuclear powerplants to ensure that thoseradioactive materials that may be released during
reactor accidents-including radioiodines-canbe measured at multiple onsite and offsite locations.
• Emergency plans should include provisions for a
prolonged radiological response effort and a clear
chain of command. Additionally, guidance should
be provided to ensure that the emergency director is promptly informed of critical information,and that State and Federal agencies are kept accurately informed of plant status and radiologicalconditions.
• Communications equipment should be provided
at all nuclear powerplants to ensure unimpeded
contact between inplant locations and all locations where offsite monitoring teams are likely toperform radiation dose rate measurements.
• Emergency plans should be suitably definitive toprovide an adequate response to a realisticallyanticipated accident under adverse conditions
such as inclement weather, minimum allowablestaff, and a rapidly developing accident.

874

REFERENCES AND NOTES
Gerusky, Reilly, and Dornsife Interview on May 3,
1979 (IE) at 53-54.
2
NRC, "Investigation Into the March 28, 1979 Three
Mile Island Accident by Office of Inspection and Enforcement," Investigative Report 50-320/79-10 (NUREG0600), at 11-2-3.
3
Laudermilch Interview on March 30,1979 (Met Ed).
4
Gingrich Interview on March 30,1979 (Met Ed).
5
Gingrich Interview on March 22,1979 (IE) at 8.
6
Kunder Interview on April 25, 1979 (IE) at 29.
7
Zewe Interview on March 30,1979 (Met Ed) at 5.
8
NRC, Regulatory Guide 1.101, "Emergency Planning for
Nuclear Power Plants," at 1.101-4.
9Statement by G. P. Miller, Station Manager, May 7,
1979, Miller dep. (Pres. Com.), Exhibit 114, at 3.
10
G. Miller Interview on May 7, 1979 (IE), Tape 158 at
20.
1

87 5

11
Herbein Interview on May 10, 1979 (IE) at 9-10,16.
12Herbein dep. at 31-32.
Statement by G. P. Miller, Station Manager, May 7,
1979, Miller dep. (Pres. Com.), Exhibit 114, at 23.
14
G. Miller Interview on May 7, 1979 (IE), Tape 159 at 1.
15
Seelinger dep. at 105-106.
16
M. Ross dep. (September 18,1979) at 13-14.
17
Herbein Interview on May 10, 1979 (IE) at 17.
18
Kunder dep at 65.
19
G. Miller dep. (September 20, 1978) at 50-51.
1320Statement by G. Miller, Station Manager, May 7,
1979, Miller dep. (Pres. Com.) Exhibit 114, at 29.
21
Metropolitan Edison Co., Three Mile Island Site
Emergency Plan 1004, Sec. 2, Rev. 1 at 23.0.

tions; and the support provided by the Burns andRoe organization, the architect-engineer for theplant, in the design, engineering, and construction ofplant modifications following the accident.

4. INDUSTRY SUPPORT
a. Introduction and Summary
The support provided by organizations and individuals from outside the General Public Utilities (GPU)organization in the response and recovery effort to
the TMI-2 accident, developed on March 28, 1979,
i n proportion with the awareness and understandingby the GPU management, including the General
Public Utility Service Corporation (GPUSC) and Met
Ed, of the extent and severity of the TMI-2 accident.
The support grew from a few isolated requests for
specific support on the day of the accident to thearrival at the TMI site on March 31 of hundreds ofi ndividuals and of truckloads and planeloads ofequipment and material from throughout the country. The mobilization of support involved nearly theentire nuclear industry in the United States and theunselfish commitment by companies and individualsof resources at their disposal. While it took a few
days to cast these resources, both human andequipment, into a structure for the recovery effort touse them more effectively, it must be rememberedthat this effort was initiated and implemented essentially without any preaccident planning by GPU or by
the industry as a whole.
This section of the report discusses the industry
support during the 10-day period beginning the dayof the accident on Wednesday, March 28, and endi ng on about Saturday, April 7, 1979. During thisti me, three phases in the development of the industry support are identified: first, the limited support
activities on March 28 and 29; followed by extensive requests for outside assistance from late March
29 through April 1, when GPU realized the severityof the accident and its potential consequences; andfinally, the integration of the outside support personnel into the developing GPU recovery organization
on April 1.
The next two subsections discuss the development of the industry support and its integration into
the recovery organization. It includes the technicalsupport for operations provided by nuclear steam
supply system manufacturers, architect-engineers,
and utility companies, and the function of industry
executives summoned to the site for assistance.
Subsequent subsections discuss the Industry Advisory Group, a think-tank of nuclear engineeringand scientific talent from across the country that
was assembled after the accident to evaluate plant
operations from a "what if" aspect; the support provided by the Babcock & Wilcox Company, thedesigner and supplier of the reactor system, in theevaluation of the continuously changing plant condi-

b. Development of Industry Support
The requests for support from outside the GPU
organization on the day of the accident, March 28,
and on March 29, were based on the limited perception of the severity and extent of the accident by
the onsite TMI-2 operations staff and by the GPU
management. With respect to the need for suchoutside assistance, this perception on March 29 canbe summarized as follows: the plant had experienced a severe transient but had been placed in astable condition; a site and general emergency had
been declared because of the radiation levels, bothon site and off site.
The requests for outside assistance on March 28
and March 29 pertain to the radiation levels. They
were initiated primarily by the plant operations staff
and by the Met Ed staff in Reading, Pa. Circumstances and developments for some of the principal requests are summarized as follows.
During the site emergency, respirators were used
i ntermittently by the onsite staff to remove airborne
radioactivity from the air they were breathing. On
March 28, the need for additional equipment wasi dentified to the Met Ed staff in Reading. Richard
Klingaman, the Met Ed Manager of Generation Engineering, immediately contacted vendors and nearby utilities requesting their assistance. One of theresults was that a member of the Met Ed staff, who
was at the Oyster Creek facility in New Jersey, returned at once to the TMI site bringing with him acarload of respirators.
Radiation Management Corporation (RMC) had awhole-body counter at the TMI site in connection
with the refueling outage on Unit 1 (a whole-bodycounter is a radiation detection device used to identify and measure radioactive material in the humanbody). RMC was requested to perform whole-bodycounting and also to assist in environmental sample
analyses and respirator testing. However, thewhole-body counter could not be used because ofhigh background radiation levels on site. It was put
i nto operation on March 30, at the offsite substation.
Additional personnel were needed to staff radiation monitoring teams. The onsite staff and theReading staff contacted the following organizations
that provided manpower and radiation survey equipment on March 28 and 29: Nuclear Support Services, Salem Nuclear Power Station, Philadelphia
87 6Electric Company, and Porter-Gertz Company.
These organizations responded promptly by sending personnel and survey equipment to the site.
On March 28, the Reading offices requested the
Tri State Laundry Company to move its mobile
decontamination laundry unit to the site. The request was based on the expectation that a large
volume of contaminated laundry would be generated, primarily by individuals working in the highly
contaminated auxiliary building.
On March 29, the Met Ed staff in Reading became concerned about the substantial amounts ofcontaminated water that had accumulated in thecontainment building and in the auxiliary building.
Although the level of radioactive contamination was
not accurately known, it was apparent that the water would have to be stored at the site prior to its
eventual disposal. Therefore, the Reading staff
made an extensive survey of suppliers for storage
tanks in the northeastern part of the country to obtain information on the availability, size, design pressure, location, and transportation aspects of suchtanks. On March 30, the information was evaluatedand extensive tank capacity was ordered. Independently, Burns and Roe initiated a similar survey atthe direction of Herman Dieckamp, the President of
GPU in Parsippany, N.J. (Dieckamp is also Presidentof GPUSC, which is located in nearby Mountain
Lakes, N.J.).
GPU and GPUSC managements believed untill ate on March 29, that the plant had been placed ina stable condition. This is evidenced by the factthat two small teams were sent to the TMI site on
March 28 and 29 to investigate the cause of thetransient and determine the necessary steps to return the facility to service. At that time, they apparently knew of no immediate need to involve outside organizations in that effort.
B&W, the nuclear steam system supplier for
TMI-2, participated in the efforts to stabilize theplant on March 28. Leland Rogers, the B&W Site
Operations Manager, at the request of Gary Miller,
the Met Ed Station Manager, served on the emergency management team in the TMI-2 control room
and assisted in the efforts to reestablish cooling of
the reactor core. The B&W staff in Lynchburg, Va.
had limited information about the plant status but
were able to analyze plant conditions in sufficientdetail on the afternoon of March 28, to recommendthat the high pressure injection flow be increased.
Communications between Lynchburg and the TMI-2
control room were indirect and the recommendation
was made through the GPU offices in New Jersey.
An open telephone line was established between
Lynchburg and the control room later that evening.

Burns and Roe, the architect-engineer for TMI-2,
offered assistance on March 28 and frequently
thereafter. The first call for assistance from Burns
and Roe was made by the TMI-2 operations staff on
March 29, requesting a determination of the waterlevel inside the containment. At this time, the requests to Burns and Roe were directed mostly toobtaining information rather than recommendations
for recovery actions.
Although the requests from within the GPU organization for outside support were limited during
the first 2 days, there were numerous offers of assistance from individuals and companies. Most of
the offers were made by telephone calls to the Met
Ed offices in Reading, and some were made to the
GPUSC offices in New Jersey. Because of communication difficulties few calls offering assistancewere received at the TMI site. The offers of assistance came from all parts of the nuclear industry, including nuclear steam system suppliers, constructors, architect-engineers, and nuclear utility companies. Many of the calls were made by individuals
i n personal contacts. However, because the exact
status of the plant was not known to the GPUSC
and Met Ed staffs, they were unable to identify
areas where assistance was required. 1
The GPUSC team, which had been dispatched to
the TMI site on March 29, concluded by that eveni ng that the plant conditions were not entirely stable
and the situation in general was more serious than
had been assumed earlier. This conclusion wasreached after talking with members of the operations staff and was based in general on the continued high radiation levels in the containment, on thel ack of progress that had been made in cooling theplant down, and on a preliminary evaluation of plantdata such as the use and operation of the highpressure injection system on the previous day.
These observations were discussed between
Richard Wilson, the GPUSC Director of TechnicalFunctions, who was directing the investigative teamat the TMI site, and Robert Arnold, the GPUSC Vice
President for Generation in New Jersey. Arnold
then apprised Dieckamp of these findings. It was
concluded that the reactor core very likely had been
uncovered to some degree on March 28, and may
have experienced extensive damage leading to therelease of large amounts of fission products. Basedon this growing awareness and understanding,
Dieckamp concluded that the full recovery from theaccident was beyond the capability of the GPU organization and additional resources were required toevaluate and respond to the existing situation. The
singular event that triggered the requests for outside support on a massive scale, and underlined the
87 7and relay information and recommendations. Thisli nk of communication was maintained on a 24-hourbasis. Similarly, many requests for assistance, primarily by site operations staff, were directed to
Burns and Roe, which also made itself available on a
24-hour basis.
The requests for assistance that originated within
the GPU organization on March 30 and 31, apparently were principally based on the recognition
that the plant was in a condition that previously had
not been considered and had not been evaluated in
the design of the plant. Dieckamp recognized thatthe best professional talent available was required
to evaluate the current status of the plant, to determine the potential for and consequences ofdeteriorating conditions, and to determine a method
to stabilize the plant.
The GPU management in New Jersey had a general understanding of the plant conditions; however,they were uncertain about the specific issues that
had to be addressed. In his interview by the Special
I nquiry Group Dieckamp stated the following:

urgency for support, was the release of radioactive
gases from the auxiliary building on the morning ofMarch 30. Dieckamp described the situation to theSpecial Inquiry Group:

It was at that point that I then sort of officially decided that we were going to need more help, more
smarts, the best smarts we could get and began
then to make inquiry throughout the industry to get
assistance to give us a hand. 2

The requests for assistance were made by manyi ndividuals within the GPU organization, both fromthe TMI site and from the GPUSC offices in New
Jersey. In retrospect, the requests originating at
the two locations can be differentiated: those fromthe site were related to problems regarding the immediate operation of the plant, while those from the
GPUSC offices were directed to a more fundamental
understanding of the plant conditions and to longer
range recovery approaches. However, there wasno clear distinction between the efforts.
The operations type problems from the site weredirected primarily to the nuclear steam supply system manufacturers, not only B&W, but also Westi nghouse, Combustion Engineering, and General
Electric; and to other utility companies, primarily
those with a B&W system. Direct telephone lines
between the site and the cited organizations werearranged by Dieckamp and Wilson. Each of thereactor vendors was advised of the TMI-2 plantstatus on March 30, and specific and potential
problems were identified for their evaluation and review. For example, the question of "how and when
could it be attempted to go to natural circulation
based on the current plant condition" was a top
34
priority concern posed to all vendors. ' Arnold,
who arrived at the site on March 30, explained to
the Special Inquiry Group the basis for the directcontacts to the vendors:[Most of the requests for assistance] were not in
relationship to clearly defined specific tasks but
rather a feeling on my part that the tasks were ofsuch a general magnitude and ... scope that weneeded people with strong basic backgrounds,
rather than narrow specialties. 5

Bernard Cherry, the GPU Vice President for Corporate Planning, who participated in making the early requests for assistance, expressed the uncertainty about specific tasks when making his contacts byasking questions such as, "What do we have to beconcerned with next? How can we construct a
defense-in-depth?" 6
The first requests were for individuals with experience and expertise in areas such as systems
analysis, core hydraulic heat transfer, liquid andgaseous waste processing, and fuel performance.
The individuals who responded to this request
formed the nucleus of a group, initially referred to as
the "Think-Tank" and later identified as the Industry
Advisory Group.
The requests for assistance from New Jersey
were made by members of the GPU managementi ncluding Dieckamp, Cherry, William Murray, theGPU Vice President for Communications, andRobert Keaten, the GPUSC Manager for Systems
Engineering. These individuals, through their many
years of experience not only in technical aspects of
the nuclear industry but also in management positions, had many personal contacts in the industry
through which most requests were initiated.
Whereas the primary objective was to mobilize expertise for the think-tank, requests for assistanceOur purpose in doing that was to make available tous as directly as possible the analytical resourcesof those other three vendors as well as B&W, principally so that they could provide for us in terms offuel analysis, thermal hydraulic analysis, advice onnatural circulation, flow maldistribution, just to havethem working on whatever problem we felt theymight be able to contribute to, usually several if not
all of the organizations
working on any given impor4
tant problem.

This statement not only identifies the purpose of
the direct communication links, but also explains thegeneral approach that was taken by the GPU sitegroup, namely, to obtain several expert opinions.
Through these direct lines, the resources of each of
the vendors were made available. In particular, theopen telephone line between the TMI-2 control
room and B&W in Lynchburg was used to request
87 8

were also made to obtain operational support. The
following is a brief summary of some of the requests
made from New Jersey and starting as early as theafternoon of March 29.

• The Electric Power Research Institute (EPRI) in

California was requested on March 29 to assist in
the evaluation of the TMI-2 accident. Edwin
Zebroski of this organization made recommendations on methods for degassing of the reactor
coolant system on March 30. He and his colleague, Milton Levenson, came to the TMI site on
April 1.
• Atomics International in California was asked forassistance in evaluating the use and installationof the plant hydrogen recombiner for the removalof free hydrogen from the containment atmosphere. This organization made available an additional hydrogen recombiner.
• R. Brooksbank of Oak Ridge National Laboratory(ORNL) in Tennessee was requested to assist in
the radioactive waste problem.
• Sol Levy in California was asked to come to thesite and assist in thermal-hydraulic analysis of
the reactor coolant system.
• Bechtel, the architect-engineer for other B&W
reactor facilities, was requested on March 31 toprovide assistance. A group under the directionof C. Judd was sent to the site. D. Stohr, Bechtel
Project Manager for the Arkansas-One nuclear
facility, was a member of the team. Bechtel had
called GPU earlier offering assistance in evaluati ng steam generator isolation methods, overheated fuel pins, and operation of a solid system.
• Late Saturday, Larry Ybarrondo and Nick Kaufman of the EG&G Company in Idaho were asked
to come to the site to assist in the core assessment and natural circulation evaluation.
• In addition to the assistance provided by thereactor vendors using direct telephone lines tothe site, Cherry in New Jersey also requested assistance from the vendors on March 30. He had
previously established a personal contact on
March 28, with each of the vendors. Romano
Salvatori of Westinghouse and Fred Stern of
Combustion Engineering sent some of their people first to New Jersey where they received abriefing on the plant status on March 31. Subsequently they went to the site. GE sent a groupdirectly to the site.
• On March 31, after becoming aware of the importance of the postulated explosion potential of thehydrogen bubble, Dieckamp contacted Dale
Myers of the Department of Energy requestingthat he identify and make available the best expertise in hydrogen burning and explosion
879

characteristics. On April 1, Wilbur Riehl of theNASA Marshall Space Flight Center in Huntsville,
Alabama, arrived at the site to evaluate (together
with Zebroski of EPRI) the hydrogen explosion
potential.
William Lee, President of the Duke Power Company, was called by Dieckamp on March 31, forassistance from his organization in plant operations. (Duke is the operator of three nuclear units, each with a B&W nuclear steam supply system.) Lee dispatched a group of five individuals
under the direction of Warren Owen, the SeniorVice President for Construction.

The personal involvement of Dieckamp in requesting additional support decreased after his arrival at the site on March 31. Requests for support
during the following days were made by individuals
working on specific problems and also in a selfpropagating manner by those individuals who started to arrive at the site.
c. Integration of Industry Support into
Recovery Organization
By March 31, people from throughout the country
were arriving at the TMI site at a steady pace in
response to GPU requests for support. Their travel
to Harrisburg was delayed in some cases becauseof unavailability of commercial flights (United Airlines
was on strike) and was expedited in other cases byusing charter aircraft. The people came primarily
from the reactor vendors, architect-engineers, utility
companies, and nuclear support organizations. Until
about April 4, the assignment of the individuals to a
specific task presented a problem because of logistical and organizational confusion. On March 31,
there were hundreds of people milling about at theObservation Center (directly across the river fromthe plant); not only individuals associated with therecovery effort, but also sightseers, members of thenews media, and others. The confusion was compounded by the arrival of trailers at the Center,
which was growing into what became known as"Trailer City," the offsite offices of the support organization. There was no single person to whom
new arrivals to the GPU organization could report.
The location for reporting was the Observation
Center, although some individuals attempted unsuccessfully to gain direct access to the site. Frequently the individuals arriving did not know who
within the GPU organization had requested theirsupport or where that person could be located.
On March 31, there existed a Met Ed plant operations group under John Herbein, the Met Ed ViceTechnical Support Group reporting directly to Wilson.
I ndividuals assigned to the control room collected
general and plant status information that was continuously requested by other elements in therecovery organization, in particular by the TechnicalSupport Group. Later, as they became more famili ar with the plans and procedures for core cooling,
they also provided guidance and background information to the operators.
Among the personnel from the reactor vendors
and architect-engineers, individuals from the B&W
and the Burns and Roe organizations were generally
more effective because of their familiarity with systems and components of the plant. Members ofother organizations had to go through a brief learni ng period to become familiar with the B&W terminology. More importantly, however, procedures
prepared by these individuals had to be carefully
checked to ensure that such procedures werebased only on B&W systems and their proper application.
Owen described the utilization of outside personnel in his interview with the Special Inquiry Group:

President for Generation, and a GPUSC technicalsupport effort under Arnold. However, an overall
GPU organizational structure did not exist at thesite. Many activities were performed and developed
concurrently by different individuals with little coordination among them. Because of the absence ofsuch a structure, people were not fully aware ofwhat support was available or where it was needed.
Eventually the integration of the support individuals
i nto an overall organization became more effective
as expressed by Keaten:

We intended to bring them in, talked to them on an
i ndividual basis about what their background andcapability was, plugged them into the organization
at a place that looked like they would fit the best;
and then we constantly encouraged these people
to come back to us, the managers, if they saw aplace where they could fit better, because theyknew their capabilities better than we did . 7

The support provided by outside organizations
can, in retrospect, be grouped into four categories.
First, the broad technical expertise that was assembled in the Industry Advisory Group, which consisted essentially of non-GPU personnel and which wasl ocated separately and removed from the site.
Second, a large contingency of systems analysts
and design engineers, mostly from Burns and Roe,that formed the Plant Modifications Group. These
two groups are discussed in separate subsections.
Third, there were individuals from the reactor ven(including
B&W),
from
other
dors
architect-engineers, and from utility companies thatprimarily supported the Technical Support Group
under Wilson. The fourth group consisted of executives from throughout the nuclear industry who provided support to GPU management in the decisionmaking process and by acting as their deputies.
However, there was no clear distinction among thefour categories and individuals could be assigned
and reassigned to different groups.

The outside support personnel were integrated into
the GPU structure; however, they did not assume ali ne responsibility in plant operations. Their function
was to advise and recommend. Reactor operatorsfrom other utilities did not perform active operation
functions but provided technical support to the Met
Ed operators licensed on TMI-2. This freed the
Met Ed operators, and more reasonable shift durations could be assigned. 8

Early in the week following the accident, company executives from throughout the nuclear industry became involved in the direction of the recovery
effort. Through their presence at the site and theirdirect participation in the activities, they were able
to determine what other assistance from their organizations was needed to contribute to therecovery effort. The executives would authorize
and make such assistance available, frequently
without a specific request from the GPU management. For example, Lee of the Duke Power Company, who came to the site on April 4, had initiatedand authorized the use of one of the Oconee Unitsto evaluate the method selected to achieve natural
circulation.

Extensive support was required in the areas ofsystem design and operation, and in particular in thearea of nuclear plant operation. This expertise wasprovided by people from the reactor vendors,architect-engineers, and utility companies. Generally, they were assigned to the Technical Support
Group under Wilson. They provided support in the
preparation and evaluation of proposed step-bystep emergency procedures on an as-needed basis
for members of the GPU group in the control room.
Most effective in their assignments were individuals
with operating experience in B&W plants. For example, Norman Pope, Superintendent of Operations
for the three Duke Power B&W plants, was able toassume the role of supervisor of one shift in the

I ndustry executives were placed in direct chargeof functional elements: Frank Palmer and Robert
Pavlick of Commonwealth Edison Company asManagers of the Waste Management Group, Warren
Cobean of Burns and Roe as the Manager of the
Plant Modifications Group, and Fred Stern of
Combustion Engineering as the Manager of the

88 0Task Management and Scheduling effort. Stern
directed the assignment of priorities and schedules
for individual tasks within the recovery organization,
and, most importantly, he coordinated these activities to ensure that overall plant objectives and priorities were met. Levenson of EPRI managed the Industry Advisory Group.
Direct support to Dieckamp, the GPU Chief Executive, and Arnold, the GPU Operations Manager of
the TMI-2 Recovery Organization, was provided
respectively by William Lee, President of DukePower Company, and Byron Lee, Vice President ofCommonwealth Edison Company, who were deputies to the two key GPU individuals. They had theauthority and responsibility to perform any function
when acting as deputy in the absence of the GPU
executives; and, more importantly, they assisted
and relieved them in performing their many functions
during long days. Owen arranged for additional
technicians and managers needed at the site.
I n addition to serving specific functions within the
GPU recovery organization, these executives werealso members of the IAG and thus were constantly
aware of any concerns by that group. They provided the GPU management with confidence and assurance that they had the full support of the nuclear
i ndustry. In their positions, they frequently acted asli aison between the GPU organization and the NRC
onsite management.
The realization by the GPU management of theneed for the participation of company executives in
the overall direction of the recovery effort was influenced by the onsite NRC management. Owen, who
had arrived at the site on April 1, as part of the Dukeassistance team, talked with Harold Denton, Director of the NRC team at the site. Denton expressed
his concerns about the GPU capability to respond tothe many and diverse issues they were facing, andabout their manpower availability, including management manpower, to keep on going around theclock. 9 On the morning of April 4, Owen called Bill
Lee in Charlotte, N.C., and informed him that he felt
uneasy about the way things were going. Owenalso stated that there were continuing problems incommunications among people at the site, that there
was a definite need for an organizational structure
for the entire support effort, and that there were
continuing difficulties between GPU, Met Ed, and the
NRC.10
Denton, in the interview by the Special Inquiry
Group, expressed his concept of the need for company management participation:

my staff in terms of what should be done next, andI felt like the operating organization of GPU needed
supplementing and in that case I did call people like
Bill Lee and Byron Lee directly, and they responded, as I recall, the very same day. And flew therewith their own shift supervisors and began to be integrated right into the operating organization ....I
think I asked Bill Lee to come. I knew he operated
B&W plants. He had a staff with experience inoperating similar plants, and told them it's his problem as to how does he get worked into the GPU organization, but that I thought GPU needed help andit needed help from anybody who had any experience with B&W plants ... 11

Shortly thereafter, Lee was called by William
Kuhns, the Chairman of the Board of GPU, who told
him that he (Kuhns) had discussed the need for
Lee's presence and participation with Joseph Hendrie, Chairman of the NRC, and Denton. Lee left immediately by charter aircraft and arrived at the site
in the early afternoon of April 4.
Dieckamp consulted with the company executives and asked for their advice on major problems
and decisions, such as the development of a baseplan to eventually achieve cold shutdown conditions
and to determine what actions were to be taken by
the control room staff in the event of any unexpected development or system failure. On April 3, the
NRC expressed to him its concern that GPU apparently did not have a firm strategy for the solutionof this problem. Dieckamp concurred in this assessment and immediately took action to develop
such a strategy:
Tuesday afternoon I closeted myself with MacMillan[Vice President of Babcock & Wilcox], Warren
Owen, Bob Arnold, Dick Wilson and a couple more
B&W guys and we just hammered out, point bypoint, what is the plan for going from where we areto cold shutdown. What is the route we are goingto take? What is the step? What is the sequence?
What is the rationale? What if this fails? What do
we do next if this fails? What do we do if the pumpfails? What were the fallback positions to thatplan? It took us about six hours to hammer that
out. There was a lot of reluctance to sign up for aplan. There was the sort of feeling that we havegot a lot more analysis to do and I just hung in
there with the things, that if we had to make the decision right now, what would it be, because that iswhat we were faced with. That, of course, in turnled to having in place in the control room, or atleast to a degree, having in place in the control
room at all times the fallback procedure. .. .We put
in place these procedures and their fallback procedures, while at the same time the NRC undertook
to do their own review of that and comment on it,
and in effect, approve, if you will. 12

I became concerned about the ability of GPU to actually carry out the instructions and procedures thatwere being developed by this industry group or by

Outside executives were active participants inthe development of the TMI-2 recovery organization
88 1

dition that previously had not been considered in thedesign and accident analysis. To cope with the situation, he requested outside organizations and individuals to come to the TMI site and provide their assistance to GPU in determining the plant conditions
and evaluating approaches to achieve a stable condition.
The first IAG members began to arrive in Harrisburg late on March 31. These members were Westinghouse and Combustion Engineering personnel
who first went to the GPU offices in New Jersey
where they received a briefing on the plant status.
The individuals that formed the nucleus of the IAG
arrived in Harrisburg throughout April 1. GPU had
arranged for the IAG to use the Air National Guard
Building at the nearby Harrisburg Airport. Most of
the individuals went directly to that building; however, others were first directed to the TMI Observation
Center. A general state of logistical confusion existed at this location due to the continuous arrival of
support personnel, visitors, construction workers,
and others. This situation was compounded by arrangements being made for the visit of President
Carter. Because of this confusion it took hours, insome cases, to direct individuals to the Air National
Guard Building.
In the early afternoon of April 1, there were approximately 30 individuals in the IAG. They exchanged whatever information they had available asindividuals. However, in their effort to evaluate theconditions of the TMI-2 plant and to make recommendations, they were continuously struggling for
information. It was in those early discussions that
individuals took the lead in identifying important
technical and management issues that would need
to be resolved; others joined these efforts according
to their expertise.
The first meeting of the IAG was held on April 1.
The IAG received a detailed briefing of the plantstatus as it was conceived at that time by the GPU
management. Dieckamp identified the following four
specific questions GPU was facing:on April 4. Although some functional elements had
evolved earlier, the effectiveness of the recovery effort appeared to be worsening because an overall
organizational structure for the interaction amongsuch elements did not exist. This uncertainty of
how and with whom to interact in the recovery organization was especially prevalent in the IAG. It led
to a growing communications problem among people at the site, in particular for those from outsideorganizations because they had the additional unfamiliarity with conditions and surroundings. Communications with onsite personnel were a problem.
Apparently no one at the site had been assigned
responsibility for communications. Furthermore,
many GPU personnel, operations staff, support staff,
and management had been working long days since
their arrival at the site. Individuals were exhausted
and easily irritated. People seemed to be picking at
each other for the smallest reasons. This conditionof organizational instability was recognized by
Dieckamp on Tuesday night, April 3.

[ When I reached the point] where I felt that I had asufficient awareness of the major blocks of effort
and their priorities that I felt I was able then to starttalking about an organization to handle those, because up to that time things were in a very ad hocstate. People were becoming somewhat restless
because of the ad hoc unstructured aspect ofit ... Wednesday morning Warren Owen and John
MacMillan grabbed hold of me and said, , Look, wehave got to organize this thing,' we closeted ourselves and began to lay out the organization structure that ultimately became established . t3

Bill Lee also participated in this effort after his arrival at the site. This organizational structure wasi dentified as the "TMI-2 Recovery Organization,"
and was implemented on April 4. It resulted in improved understanding among individuals andgroups. Particularly, the interactions between therecovery organization and the NRC improved as expressed by Dieckamp:
It seemed to me that our composite organization
functioned a heck of a lot more smoothly all of asudden, whether it was less sort of competition,less regulator, regulatee, more of a combined composite approach to the problem. A lot of things
seemed to just all of a sudden fall in place with theestablishment of that organizational structure. I
don't know what other factors might have contributed to the kind of maturing of the relationship that
occurred on that time scale, but that is how I recall
it happening.

1. What is the physical condition of the reactor corewith respect to the degree of damage and its
coolability?
2. What are the unique problems associated withthe cooling system, and in particular, what are
the specific problems associated with the bubble
of noncondensible gases in the reactor vessel
with respect to its size and explosion potential?
3. What reliable methods are available to achieve
cold shutdown?
4. What are the problems associated with the radioactive waste and radiation releases?

d. Industry Advisory GroupThe Industry Advisory Group (IAG) was formedon the initiative of Dieckamp, who realized late on
March 29, that the TMI-2 plant was in an upset con-

88 2

Dieckamp was unable to provide the IAG withany specific guidance on how to attack those prob-

tion were assigned to the IAG. They provided valuable information on the design, function, and location of the systems.
The function of the IAG, as originally perceived
by Dieckamp on March 30, was to provide GPUwith an overview evaluation of the conditions of theplant. The group was to look at these conditions
from any imaginable viewpoint and advise GPU ofthe stability of the plant and the consequences ofnot maintaining the stability. The four questions
identified to them by Dieckamp for their consideration fell within this scope. However, as the situation
at the site developed, the scope of the IAG waschanged. One assignment for the group was to review and evaluate operations and modifications proposed by other elements of the recovery organization. In this function the IAG would provide additional confidence in the appropriateness of the proposed activities. An example is the review of thedifferent methods for establishing natural circulationthat were under review. Another assignment was toindependently assimilate, integrate, and interpret
plant status information and data. The IAG would
then decide and advise the TMI-2 Recovery Organization, normally through the Technical Working
Group, whether the problems had been identified in
sufficient depth. By about mid-April, the IAG assumed as a third responsibility the review of detailed procedures for plant recovery operations.
Arnold described his perception of the first twofunctions of the IAG as the following:
I saw the Industry Advisory Group as primarily agroup of very knowledgeable, experienced engineering and scientific people who would sit off at
the side and do two things. They would review
what we were doing, and we could influence thedegree of detail to which they conducted that review because we could flag to them specific kindsof things we wanted them to really look at in agreat deal of detail. So there was that type ofreactive mode on their part. And secondly, they
could take the information which was available tothem-and we tried to make as much of the raw
data, so to speak, available to them as we could,
from a practical standpoint-and they could independently attempt to assimilate, integrate, and interpret that data and reflect back to us where wewere with our line people, addressing the rightproblems, when our scope of activity was sufficient,when we were foreseeing the right types of problems that may be developing. 17

l ems. In the SIG interview he recalled the following
situation:
Look, I don't know all of you guys in great detail,and I don't know each of your ... greatest
knowledge, but I think you yourselves know where
you can best contribute to these four areas.
Conglomerate yourselves into these groups thatare working on the problems and go to work. Thatis about as much as I can tell you what to do. 15

I n a second briefing late on April 1, Denwood
Ross and Roger Mattson of the NRC presented theirview of the situation and the critical problem areas.
Hendrie, the Chairman of the NRC, was also present
at the meeting. One of the major subjects of discussion was the issue of the explosion potential of
the hydrogen bubble in the reactor vessel.
Zebroski, of EPRI, at that time strongly objected to
the NRC concept and emphasized that this was not
a problem. 16
Subsequent to the meeting, the IAG organized itself under the direction of Levenson of EPRI, with
Sol Levy, an industry consultant, and Zebroski as
his deputies. It was a loosely structured group ofi ndividuals with a very high degree of expertise in avariety of disciplines. The group included representatives from the reactor vendors, research organizations, utility companies, academic institutions, national laboratories, and architect-engineers. While
the original group at the site consisted of approximately 30 individuals, an enormous amount of additional support in the form of manpower and services
was made available to the IAG through their respective home organizations. In this sense, the IAG was
self-aggregating; eventually more than 100 persons
had participated, for at least a short time, as
members of the group.
The lack of information was identified as a problem on April 1, and continued to persist and reduce
the efficiency of the IAG for some time. This struggle for information applied not only to the current
plant conditions but also the design and normal
operating conditions of the plant. This condition
gradually improved when GPU assigned a few
members of its staff to the group. These individuals
provided the IAG with updated information on theplant status, plant characteristic data, and TMI-2
background documentation such as the Final Safety
Analysis Report and plant drawings. They also
identified individuals within the GPU staff with expertise in areas of interest to the IAG, and expedited
communications between the IAG and these individuals and other elements of the TMI-2 recovery organization. On about April 7, this GPU group also
assumed the function of documenting the writtenmaterial prepared by the IAG. In addition to the
GPU staff, members of the Burns and Roe organiza-

88 3

On the evening of April 1, the IAG began considering the four top priority issues identified to them.
A major contribution by the IAG was the review andevaluation of the explosion potential of the "hydrogen bubble" inside the reactor vessel. This effort
under the direction of Zebroski, with the participation of Riehl of NASA, demonstrated convincinglythat this issue was not a problem. However, theIAG did not become fully effective until about aweek after the accident began. Dieckamp expressed the following view:I t really did not start having a significant effect until
we set up the organization and people like Zebroski
and Levenson sat in on the ... technical working
group and began to make direct input there ... forthe first several days the role of the Industry Advisory Group was one of getting up to speed andbeginning to look at some of the longer range
i ssues ....I don't think in the early days they had asignificant impact on the direct operations. 18

Arnold, the Manager of the TMI-2 Recovery Organization, similarly stated the following:

I AG was informal. Task assignments were made on
a priority basis and results frequently had to beavailable in a short time. When a particular problem
came up for which additional expertise was required, Levenson, as the director of the IAG, would
contact the appropriate organizations or individuals
and request their assistance, including their presence at the site. The problems assigned to the IAG
for consideration and evaluation during the firstweek after the accident included the following:• examination of controlled depressurization toachieve long term cooling statushydrogen in reactor coolant systemdose assessment
natural circulation with solid pressurizer
operation of reactor coolant pumps at reduced
speed• removal of airborne radioactivity from containment• i nvestigation of particle bed• degradation sequence study for the event ofplant systems failure• primary system cooling modes that use primary
components as a heat sink• safety of various cooling processes• use-of secondary system for long term cooling• transfer of hydrogen from waste gas storagetank to the containment

•
•
•
•

Prior to the establishment of this organization, themiddle of that first full week following the accident, I
had very little interplay with that group.

Because of this absence of an organizational
structure during the first days, confusion existed
among the groups of the recovery effort. The interaction between the IAG and the other elements
was essentially between individuals involved in aparticular effort. Once the formal TMI-2 Recovery
Organization was established on April 4, the information flow between elements of that organization
was accommodated through the Technical Working
Group. This was a type of executive committee for
operations assisting Arnold as the GPU Operations
Manager. The managers (or their deputies) of thegroups of the recovery organization attended thetwice-daily meetings of the Technical Working
Group, where assignments, priorities, and recommendations were discussed. The B&W and Burns
and Roe organizations, although not identified as
specific elements in the TMI-2 Recovery Organization, were also represented at these meetings.
Levenson normally represented the IAG. Dieckamp
maintained contact with the group through occasional attendance at these meetings. The Technical
Working Group meetings identified the activities for
the IAG and coordinated them with the overall
recovery effort; however, the direct interaction
among all staff, IAG and others, continued. Arnold
stated the following to the Special Inquiry Group:

A report of the IAG assessment was written foreach of these activities; the report was then used asa basis for discussions at the meetings of theTechnical Working Group.
The development of the entire industry support
effort, and in particular that of the IAG, was shaped
to a large degree by the interaction between the
GPU organization and the NRC after the arrival of
Denton at the site on the afternoon of March 30. As
discussed earlier, the need for broad technical expertise to evaluate the situation at TMI-2 and to
determine methods to achieve more stable conditions was realized by GPU management late on
March 29. Requests for such support were then initiated by GPU management from New Jersey
throughout March 30, and from the site on March
31.
Denton became concerned later on March 30,
about the capability of GPU to provide sufficient
manpower and expertise to the recovery effort. In a
telephone call at about 7:00 p.m. on March 30, withLee Gossick, the Executive Director for Operationsof the NRC in Bethesda, Md., Denton commented:

We tried very hard to ensure there continued to bewhat I might call staff-to-staff communications,coordinations, flow of information and status, evenafter the formalization of this organization; because
the time restraints that we were faced with or theti me demands that we were faced with certainly
would not have been reflected properly if we had
insisted on all of that type of activitr coming up
through the Technical Working Group.

This method of staff interaction provided for implementation of decisions reached at the Technical
Working Group meetings. The functioning of the

The utility is a little shy, in my view, of technicaltalent. We outnumber them. They are pretty thin.
I' m trying to convince them to bring in comparable

884

B&W. This was being done basically throughWilson's group. We had Burns and Roe working
heavily. I think one of the problems that existed inthat first 2 or 3 days was that without the kind offormal organization that we put in place in the middle of the week, I was not able to adequately convey to Stello and Denton the full scope of activities
and resources that were going on at that time.
I had to speak too much in general terms and I
didn't have enough detailed information as to all of
the things that were being done. They, I think, inretrospect-I thought at the time-failed to haveconfidence or full perception of what we alreadyhad underway in that Friday-Saturday-Sunday
24[ March 30-April 1] ti me frame.

l evels from their own organization. Their cooperation is good, but it is obvious that they are a small
outfit here and the guys are getting swamped withdemand.

Based on the interview by the Special Inquiry
Group where he commented on this statement andprovided further detail, Denton had two concerns.
One concern was the difficulty his staff experienced
i n trying to obtain plant-specific information-suchas containment volume and elevations of safety
grade equipment inside the containment-that wasneeded to perform an independent NRC assessment of existing plant conditions. Denton expressed the need for this information as the followi ng:

The foregoing statement indicates that the communications between the GPU and NRC managements regarding urgency and type of outside support were ineffective. We now know GPU had initiated actions, but the NRC was unaware of these.
Furthermore, while GPU requests were for technicalexpertise in a broad spectrum of subjects, the NRC
also was looking for technical staff within GPU that
could provide plant-specific design, operations, andstatus information. Although both managements
realized the need for outside support, they did notcoordinate the requests for such support and did
not apprise each other of their respective efforts.
Denton expressed his concern to the White House
about the GPU technical capability and need foroutside support on March 31, and passed on thenames of some senior executives within the nuclear
could effectively assist inindustry who he thought25
the recovery efforts.

I wanted GPU to get in the mode where they could
answer any questions my staff raised to get into a
more normal mode of NRC license review. '2

Wilson, the GPUSC Director of Technical Functions,also recalled in his interview by the Special Inquiry
Group that the unavailability of basic plant data andi nformation created a problem in the response effort.
Denton's second concern was the apparent absence of an industrywide involvement in the ongoing
activities, in particular the lack of participation by
B&W. This understanding by the NRC of the GPU
i nitiated and industrywide support effort resulted ini nteractions between the two organizations. Denton
recalled that he informed Dieckamp of his concerns
on March 30 without requesting any action by GPU:It was more of an inquiry,' What are you planning todo?' And I seem to have had the feeling that whatever they were doing was not sufficient, and thatwhile they did have some plans and something wasgoing on, it just didn't satisfy me. I didn't direct him
to do any more.
I guess I would have to characterize that phone
call as an information gathering phone call; and getting an answer that really didn't satisfy me and notknowing what the next course of22action would bewhen I terminated that phone call.

Denton assumed that the White House subsequently played a large role in requesting these individuals to provide their personal and companywide
support to the TMI-2 recovery effort. However,
Watson, of the White House staff, apparently did not
make any direct contacts with these individuals but
called Dieckamp to advise him on Saturday morningof the NRC concerns:
I underscored the sense of urgency that Harold
Denton felt and asked the company's cooperationi n getting those people assembled as quickly as
possible. Mr. Dieckamp pledged his fullest support
for his company to get that done. And in fact, it
was done quickly. 26

Dieckamp recalled that Denton contacted him on
March 31. At about the same time he also received
calls from Hendrie and Jack Watson of the WhiteHouse staff with the same message, urging GPU tobuild up the support with experts from throughout
the industry. 23 Arnold recalled the situation at thatti me as the following:

Dieckamp informed Watson of the GPU support
activities already initiated at that time, but it reasonably can be assumed that the calls made by him on
March 31 increased in urgency as a direct result of
this request by the White House.

I think during that time period on Saturday [March
31] I was identifying to Stello [Victor Stello, NRC Incident Response Action Coordination Team] and to
Denton on occasion what resources we had worki ng, what the scope of activity was that we were
gearing up with.
We were at that point getting Westinghouse
geared up, we were getting CE and GE as well as

The lack of communication between NRC andGPU management in mobilizing the industry support
effort became evident during the first week following
885the accident. Dieckamp recalled the following after
arriving at the site on March 31:

I began to realize that concurrent with this formation of the IAG, the NRC fellows had their own network out that was assessing all kinds of organizations, vendors, contractors, their national labs. I
guess over the next few days we found that someof these organizations were finding themselves getting the same or similar or slightly different questions from the two sources, one from us and one
from the NRC and we had a little bit of confusion
occasionally out in some of these contractor shops
in terms of who is calling what shots.
Again, I think those things worked out. They
were not really a critical problem other than a bit ofa very minor piece of inefficiency, and that is a neutral word .27

The IAG assisted the entire TMI-2 Recovery Organization, including the NRC, by providing a broad
range of expertise in any area of concern. The
group analyzed specific plant conditions and theirsafety implications, based on fundamental scientificand engineering principles. The group analyzed theoverall plant status with respect to the potential for
deterioration of the conditions, including conceptual
approaches to avert such deterioration. The IAG
also contributed to the development of the longrange plan to ultimately achieve stable plant conditions. In performing these activities, the group provided the management of the recovery organization
with assurance and confidence that the operational
steps to be taken would not lead to unstable plantconditions. Through the IAG, advanced methods ofanalyses-such as the diagnostic efforts by Norbert
Ackermann of Technology for Energy, Inc.-wereapplied to the recovery effort.
The problems encountered within the IAG and in
its interaction with the other elements of the TMI
Recovery Organization were seldom of a technicalnature. During the interviews by the Special Inquiry
Group, the technical problems were characterized
frequently as "legitimate differences in technicalopinions." They existed not so much within the IAG
but between this group and other elements of theorganization. However, in such cases a consensus
was reached on how to proceed.
The location of the IAG at the Harrisburg Airport,
removed from the confusion at the site, contributed
to a rational mode of operation. The size of the IAG(not more than 40 members at any time) contributed
to its effectiveness. More people easily could havecreated confusion and management problems within
the group. Because of its size, the free exchange ofi nformation and ideas within the organization wasenhanced.
The performance of the IAG was reviewed withmembers of the group and individuals who were as-sociated with it. The following comments were expressed almost as a consensus.

• The major contribution of the IAG was the confi-

dence and assurance it provided to the GPU and
NRC management that the existing conditions at
TMI were controllable. This confidence not only
permeated the staff of the organization but also
was expressed publicly.
• The availability of the IAG at an earlier date-for
example, on March 29, instead of on April 1possibly would have made only a small differencewith respect to the subsequent physical events.
The IAG potentially could have contributed to an
earlier understanding of the severity of the accident. More importantly, it could have advised
GPU and NRC management of the situation, andthus could have reduced the misunderstandings
and concerns of the public and the technicalcommunity.
• The expertise that became available in the IAG
does not exist and cannot be expected to exist
within each utility company operating a nuclear
powerplant.
• To be more effective in potential future operations, an industrywide effort should be initiated topreplan and coordinate the composition andoperation of such a group.
e. Babcock & Wilcox Support Effort
The Babcock & Wilcox Company (B&W)
designed and supplied the nuclear steam system for
TMI-2. The design came out of the Nuclear Power
Generation Division headquartered in Lynchburg,
Va. At the time of the accident, Met Ed had a master services contract with B&W that called for assistance in the review and evaluation of the operationand performance of the nuclear steam system on an
as-needed basis. Leland Rogers was the Site
Operations Manager from B&W assigned to TMI Units 1 and 2 since 1972. Before March 1979, additional B&W personnel were assigned to TMI-2 tocomplete certain aspects of the startup activities.
The assistance by B&W in the response to the
TMI-2 accident was provided in two ways: the onsite support by the B&W site staff, and the support
by the B&W offices in Lynchburg. In the first case,
Rogers, during a call at about 6:00 a.m. on March
28, was requested to report to the Unit 2 control
room. He arrived on site at about 7:00 a.m. and became a member of the management team reporting
to Gary Miller, the Station Manager. Roger's principal duties were to assist the Met Ed staff in thecontrol room in the evaluation of plant conditions, to88 6

make recommendations concerning corrective actions, and to establish and maintain contact with
B&W in Lynchburg. He attempted to contact thestaff in Lynchburg at about 7:30 a.m. but was not
successful because they had not yet reported forwork. In a second call at about 7:45 a.m., Rogers
contacted William Spangler, the B&W Manager forStartup Services, and advised him of the incident.
He provided some specific plant status information:that the plant had experienced a loss of feedwater,
turbine trip, reactor trip, and initiation of high pressure injection; the reactor coolant drain tank rupture
disc had burst; there were indications of fuel failure;a high radiation level in the containment dome had
been measured; reactor coolant pumps were
tripped; there was an indication of primary to secondary system leakage; and a site emergency had
28
been declared.
A second call from Rogers to Lynchburg wasscheduled for 9:30 a.m. to provide additional andupdated information. The call did not take place because, by this time, Rogers was devoting his efforts
to the control room management team and longdistance telephone communications from the control
room were difficult to establish. Instead, communications from the control room to Lynchburg
throughout the day were conducted through local
calls to the private residence (local dialing) of Greg
Schaedel, a member of Rogers' staff. It was not until 6:30 p.m. that a direct communications link
between the Unit 2 control room and Lynchburg
was established.
Based on the Special Inquiry Group's interviewsof the GPUSC and Met Ed staffs, the requests by
GPU for assistance from B&W in Lynchburg, andtheir participation in the decisionmaking process on
March 28, were minimal. During the morning, B&W
was requested (through Schaedel) to send two radiation chemists to the site to assist the plant chemistry staff in an evaluation of the water that had beentransferred from the containment to the auxiliarybuilding. Another request was for an evaluation anddevelopment of procedures to start one of the four
reactor coolant pumps. This request was made atabout 7:00 p.m. in a conference call between theoperations staff at the site, the GPU technical staff
Jersey, and the B&W staff in Lyni n New
29,30,31
chburg.
I n contrast, the activities that developed at the
B&W offices in Lynchburg as a result of the telephone call from Rogers at 7:45 a.m. were substantial. Spangler informed his management of theTMI-2 event, and a task force of about 20 technicaland management personnel was briefed on the
TMI-2 situation at about 9:00 a.m., based on the in-formation available. The task force concluded thatthe plant had gone through a transient that was not
fully understood and that it was a serious situation.
A list of specific information needed to more fully
understand and evaluate the TMI-2 situation was
prepared for discussion with Rogers in the telephone call scheduled for 9:30 a.m. It was also decided to immediately dispatch to the site, by charter
aircraft, three engineers with expertise in theanalysis of a loss-of-feedwater transient to assist
Met Ed in the evaluation, and to provide Lynchburgwith the more detailed information needed to determine requirements for startup of the plant. On arrival at the site, the engineers were unable to gain
access to or make contact with Met Ed, and soj oined Schaedel at his residence.

The participation of B&W Lynchburg in the TMI
response effort on March 28 was severely handicapped by the absence of direct communications
with the control room. Use of the indirect link ofcommunication through Schaedel resulted in delayed, outdated, incomplete, and inconsistent information being provided to Lynchburg, as well as extreme difficulty in making recommendations fromLynchburg to the control room. An additional link
for communications to the site was available intermittently through James Floyd, the Met Ed Operations Supervisor for TMI-2, who was in Lynchburg
at the time. He was able to communicate directlywith the Unit 1 control room. James Deddens, theManager of the B&W Project Management Department, was the top B&W management official in Lynchburg in the absence of John MacMillan, the B&W
Vice President, who was out of town. Deddens
made repeated requests that day to Robert Arnold
of GPUSC in New Jersey and to Richard Klingamanof Met Ed in Reading, Pennsylvania, to make adirect line available between the control room andLynchburg. As stated earlier, this was finally accomplished at about 6:30 p.m.

B&W Lynchburg participated on March 28, in two
essential activities: the initiation of the highpressure injection flow and the starting of a reactor
coolant pump. At around noon, additional information on the sequence of events and plant conditions
had become available to B&W Lynchburg. Whenreactor coolant hot-leg temperatures were finallycommunicated, Lynchburg quickly realized that superheated steam was in the hot legs. B&W wasaware that the four reactor coolant pumps had been
turned off and the high pressure injection (HPI)
pumps had either been turned off or throttled.
Based on the hot-leg temperatures, B&W recommended that a minimum HPI flow of 400 gallons per
minute be established to ensure removal of decay
88 7

heat from the reactor core to achieve subcooled
conditions. Lynchburg initially did not get this message directly to the Unit 2 control room; they instructed Schaedel at the site and Floyd in Lynchburg to relay this recommendation to the Unit 2
control room. At about 2:00 p.m., Deddens called
Arnold in New Jersey to apprise him of the B&W
evaluation and conclusions. He recommended thatthe HPI flow be increased and maintained at aminimum level of 400 gallons per minute. However,it was not until 4:30 p.m. that the recommendation
finally was implemented by the operations staff inthe control room. 32 I n the opinion of B&W, this del ay was not the result of a disagreement by the control room staff on the recommendation. Deddens
has recalled that:
The impression I have is one of, let's say, a feelingof frustration in not being able to get that recommendation clearly defined and communicated to thecontrol room. 33

Arnold of GPU did not remember this recommendation but he also stated that B&W may well havemade such a recommendation to him. 29 The othermajor activity was the B&W participation in starting
one of the four reactor coolant pumps to reestablish
forced reactor coolant flow through the core. The
need and procedures for starting a pump were discussed in a conference call at about 7:00 p.m.
B&W developed step-by-step procedures andmaintained direct contact with the control room
while the pump was started. In a final call at about
8:30 p.m. on March 28, Deddens discussed theplant status with Arnold and advised him that B&W
would be available to him at any time.
A number of telephone contacts were made on
March 28, between the NRC and the B&W Licensing
Division in Lynchburg, mostly for the exchange ofi nformation and to provide the NRC with specific details on B&W systems and components. However,specific action by B&W apparently did not result
from these calls. On March 29, at about 2:00 a.m.,
Donald Roy, the Manager of the B&W Engineering
Department, was called by Victor Stello, a memberof the NRC Incident Response Action Coordination
Team (IRACT) in Bethesda, Md., but neither recalled
the specific circumstances or substance of the call.
However, the call did result in the reconvening of
the senior members of the B&W technical staff at
the B&W offices to evaluate the plant conditions.
A specific issue discussed between the NRC andB&W on March 29, was the bubble in the primarycoolant system concerning its composition and explosion potential. In the evening of March 29, the
NRC in Bethesda, Md., requested B&W to determine
the maximum possible oxygen generation rate andcontent in the reactor vessel. Donald Nitti was the
88 8principal individual of B&W involved in this issue; theB&W Licensing Division provided the liaison with the
NRC. Nitti calculated a maximum oxygen concentration of 5.5%, exclusive of the effect of dissolvedhydrogen in the reactor coolant recombining withfree oxygen to reduce this concentration. The
specific calculations performed by B&W weretelecopied to the NRC late on March 29.
Although the bubble issue was of extreme concern to the NRC and was subsequently discussed
extensively between the NRC and B&W, there wasapparently little interaction on this issue with GPU.
Arnold recalled in his interview by the Special Inquiry Group that he was aware of a hydrogen explosion concern on March 31, but is not sure if thisrelated to the containment or the reactor vessel.
His first real awareness of the explosion potential in
the reactor vessel came about on April 1, when
Roger Mattson of the NRC briefed Harold Denton
35.
before President Carter's arrival at the site. 34 'The B&W support became a significant elementin the TMI-2 recovery effort. It reached its fullstrength approximately 5 to 6 days following the accident. The B&W Lynchburg support organizationthat was established on March 29, was staffed 24
hours per day. Overall direction was provided by
Deddens with an Operations Manager on each shift.
I ndividuals with expertise in areas such as fluid systems, long term cooling, radiation chemistry, safety
analysis and event sequence, plant design, and fueland core analysis were assigned to each shift. In
addition, the entire B&W organization in Lynchburg
was available on an as-needed basis. The main
participants were located in the Project Control
Center, a large conference room provided withneeded background information such as drawings
and safety analysis reports. Direct telephone lines
to the TMI-2 control room and support organizations at the plant site were established and maintained, in addition to other telephone lines. The
substance of telephone calls and meetings wasrecorded, and in some cases tape recordings were
made. By the weekend most of the analyses andrecommendations were made in written form by the
Lynchburg organization and telecopied to the site.
Copies were also provided, when appropriate, to the
GPUSC, the Burns and Roe organization in New
Jersey, and the onsite NRC group.
I nitially, the B&W support was provided directly tothe operations staff in the Unit 2 control room. Support was later coordinated by Richard Wilson of
GPUSC after he arrived at the site on March 29.
The B&W support was directed to the identificationof the plant status and to the evaluation and recommendation of specific actions such as methods fordegasification of the primary system, reactor

come away with the feeling that B&W was also in a
response mode, that they were answering theirphone calls, but seemed to know even less about
critical parameters than we did before I left
Bethesda.
There was a lot of information and a lot of analyses that we wanted done that only B&W could do,
and in that case we wanted GPU to get B&W tomake them and to produce people from B&W who
understood their systems in sufficient depth. .. 38

coolant pump operation stability, and alternative approaches for achieving natural circulation. In addition, B&W provided specific information such as
drawings and analyses of the reactor and othersystems and conditions.
The nucleus of the B&W group at TMI was the
B&W site organization under Rogers. The three engineers and two radiochemists dispatched fromLynchburg to the site on March 28 became part ofthis group. On March 30, a B&W expert in reactor
noise analysis arrived at the site to evaluateanomalies in the signals from the reactor coolant
flow and pressure instrumentation. By April 2, theB&W site group had increased to about 30 people.
They provided more immediate support to theTechnical Support Group under Wilson than did the
Lynchburg organization, and participated in the writi ng and review of step-by-step emergency procedures involving the reactor system and its components.
On April 2, the entire onsite B&W effort cameunder the direction of MacMillan, Vice President of
B&W. The interaction of B&W and the TMI-2
Recovery Organization took place in different ways.
Although there was no specific B&W element identified in the TMI-2 Recovery Organization, B&W
operated as an organization, as evidenced by a
B&W trailer at the site. There were different interfaces between B&W and the TMI-2 Recovery Organization: the representation of B&W in theTechnical Working Group by MacMillan; the interaction of the B&W Lynchburg and onsite groups with
the Technical Support Group; and the interaction
with the IAG. B&W was represented on the IAG toprovide liaison between the two organizations on issues being considered by both of them. The mostnotable are the methods and criteria to achieve natural circulation. The first interaction on this issue
was a briefing of the IAG by the B&W staff fromLynchburg at TMI on April 2. Subsequently, there
were many more communications on this subject,i ncluding discussions in Lynchburg.

Arnold, while understanding the concern of Denton, did not consider the B&W support to be inadequate. Nevertheless, he called MacMillan, informed
him of the NRC concerns, and requested and authorized the full support of B&W. He summarized
his understanding of the conditions as the following:

I didn't have the impression prior to that that B&W
was holding back in any sense. Based on theconversation I had with John MacMillan, I am notsure they were. I don't know that I asked him
specifically about that, but I certainly felt from thatconversation that MacMillan was glad to have thatsort of coverage of what he was doing, but that by
and large he was already underway on that level ofactivity anyway.37

Another interaction by the NRC with the development of the B&W support effort occurred on April 1,
after the NRC briefed the IAG on its perception of
the major issues. Denton was concerned that B&W
was not represented in the group and advised
Dieckamp. Dieckamp acknowledged this fact andexplained the following:
I think what really happened to the B&W people,
because they had other people on the site, whoever of B&W arrived just got co-opted into that activity on site. 38

Dieckamp immediately called MacMillan requestingthat B&W be represented at the site by high level
management. MacMillan arrived on April 2, withsenior engineers and, as stated earlier, briefed the
I AG of the B&W perception of the plant status andi dentified the major problems facing them.

The development of the B&W support effort occasionally was affected by Harold Denton of the
NRC, who arrived at the TMI site on Friday afternoon, March 30. On Friday night or Saturday morni ng, he expressed to Dieckamp and Arnold his concern for adequate support by the industry in general, and by B&W in particular. Denton recalled thefollowing:f. Burns and Roe Support Effort
The Burns and Roe Company was thearchitect-engineer of the TMI Unit 2. As such, thecompany had within its organization individuals
knowledgeable and experienced in the design,
equipment specifications, performance, interactions,and layout and location of secondary and auxiliary
systems, and of components and plant structures.
The participation of Burns and Roe in the response
effort, like most other organizations, was initiated by
a GPU request and grew in proportion with thecomprehension of the severity of the accident by

Whatever it was, I didn't find very reassuring as insufficient depth or scope... I think at the time I wasjust inquiring of him what his plans were and letting
him know that we had all these questions that hecouldn't answer. And I recall having talked to somepeople at B&W during that day and seem to have889

the GPU management. During the height of its involvement in the recovery effort, more than 300 individuals of the Burns and Roe organization wereactively participating in the support effort.
Before March 28, the Burns and Roe activities for
TMI-2 were conducted by a Project Group of approximately 40 individuals located in Paramus, N.J.
The group was directed by Scott Dam, the ProjectManager, who reported to Warren Cobean, Vice
President for the Project Operations Division. The
activities of the Project Group included updating ofplant drawings to the as-built configuration, planningof plant modifications to be made during the first
TMI-2 refueling outage, and the design of facilities
and systems not covered under the original construction contract. (The group was performing similar functions for the Oyster Creek plant of Jersey
Central Power and Light Company.) In addition to
the Project Group, three technicians at the site
coordinated the Burns and Roe effort with GPU andthe Met Ed site organization. Richard Brownewell,Burns and Roe Site Engineer, managed the effort.
Burns and Roe officials were first informed of theTMI-2 accident at approximately 9:00 a.m. on
March 28, in a telephone call from Brownewell to
Cobean. Brownewell reported that he was unable
to get onto the site because a site emergency had
been declared, but he had no detailed plant status
i nformation. Cobean contacted Richard Wilson of
GPUSC and told him that Burns and Roe would beready to assist in whatever form necessary to
respond to the event. There were no further contacts between Burns and Roe and GPU on the dayof the accident.
On March 29, after learning about developments
at TMI through the news media, Cobean contacted
Arnold to inquire about the plant status and reiterated that Burns and Roe was ready to make any service available. Arnold indicated that GPU suspected
the core had been uncovered; however, he made norequest for Burns and Roe assistance. 39 Later on
March 29, Burns and Roe received the first request
for assistance from the TMI site. The request wasfor a calculation of the water level inside the containment, based on the water levels in various tanks
that had emptied into the reactor coolant systemand spilled into the reactor containment building.
The request was based on a concern for potential
flooding of instruments and equipment inside containment. A level of 2 feet of water was calculated
and reported to the site. Although this level did notcause any flooding, it did cause concern within the
Burns and Roe organization. However, no further
call was made to apprise GPU management of the40
abnormality of the water level.

Additional requests for assistance soon followed
and continued to grow in number and scope during
the next days. The requests originated at the site,
primarily from the group under Wilson, and at the
GPUSC offices in New Jersey. During this time,
Cobean received numerous direct calls from
Dieckamp to discuss the evolving situation andunderstanding of the TMI-2 conditions. The requests were for information on system and equipment performance and capability, special studies,answers to postulated "what if" situations, designs
for interim systems and system connections, andrecommendations on methods to increase plant stabili ty. They related primarily to concerns for continued decay heat removal capability, control of primary coolant system temperature and pressure stabili ty, available methods of primary coolant systemdegasification, and methods to minimize the releaseof radioactive gas and fluids to the environment.
The last issue was raised by Dieckamp and resulted
i n a nationwide search for large tanks that could be
used to store radioactive fluids and house activatedcharcoal (an identical search for tanks was underway at that time by the Met Ed offices in Reading).
As a result of the increasing requests for assistance, in the late afternoon of March 29, Cobean instituted a Burns and Roe response organization thatprovided support on a 24-hour basis. The nucleusof the organization was the Project Group, which
was quickly supplemented by members of theForked River Project Group and other resourcesfrom throughout the Burns and Roe organizationand soon reached a size of about 200 members.
Direct telephone lines to the TMI site were installedat the offices in New Jersey to facilitate the effortsof the response group.
Based on the many discussions on March 29 and30, between Burns and Roe and the TMI site, GPU
i n New Jersey, and B&W in Lynchburg, Va., Cobean
decided on March 30, that it would be beneficial if
closer and more direct communication links were
established between Burns and Roe and B&W. On
March 31, he dispatched two engineers to Lynchburg to provide B&W with information on systems
designed by Burns and Roe, and to provide technical liaison between the two organizations.
Also on March 31, Dieckamp requested Cobean
to join the IAG and to provide TMI-2 plant specificexpertise to the group with respect to the design
criteria and installation and operation of secondary
and auxiliary systems. In addition, Burns and Roe
was requested to provide TMI-2 documentation andrecords, including as-built drawings, mechanicalflow diagrams, system descriptions, electrical oneli ne diagrams, general arrangement drawings, and89 0

concern over the consequences from a loss ofelectrical power to the plant had been raised by the
IAG. The potential consequences of such a situation were severe enough in the opinion of Cobeanthat he immediately initiated the steps for installationof two 2500 kilowatt diesel generators and obtained
the concurrence of Arnold afterwards.
Burns and Roe provided the management andthe majority of manpower to the PMG; however,other industry organizations also participated in theeffort. Westinghouse supplied a substantial groupof engineers and designs for an augmented decay
heat removal system and for the decontamination of
the diesel generator building and of the auxiliary andfuel handling buildings. The staff of the PMG also
included manpower from United Engineers and Gilbert Associates. The implementation of plant modifications (including installation of equipment) was
performed by skilled craftsmen under supervision
by Catalytic Engineering Company.
A less apparent but important contribution provided by Burns and Roe was the availability of
Cobean as a technical consultant and management
executive to the GPU management.

copies of the Final Safety Analysis Report. A groupof about 10 individuals under the direction of Cobean
arrived at the site on April 1 with the requested information, and went directly to the IAG offices.
The participation of the Burns and Roe organization in the TMI-2 support effort took place in many
forms. At the TMI site, the organization participatedi n the IAG; provided the majority of manpower, including management, to the Plant Modifications
Group; provided manpower to other elements of therecovery organization such as the Waste Gas
Management and Technical Support Groups; was amember of the Technical Working Group; and acted
as a consultant to Dieckamp. More than 100
members of the Burns and Roe staff were at thesite. In addition, more than 200 members in New
Jersey provided the backup to the site staff. During
the time of Cobean's active assignment to the IAG
from April I through April 3, Cobean was associatedwith the IAG subgroup in evaluating alternate
schemes, including considerations of loss of offsite
power, to bring the plant to a cold shutdown condition. Ed Wagner, the Burns and Roe Deputy Director for Engineering, participated in the subgroup
under Ed Zebroski evaluating the core damage, including the hydrogen bubble concern. Burns andRoe also provided the IAG with manpower with
TMI-2 expertise and with the technical informationli brary.
On April 3, Dieckamp requested Cobean todevelop, staff, and direct the Plant Modifications
Group (PMG) in the TMI-2 Recovery Organization,
which was being developed at that time. The
responsibility of the PMG was the design, engineeri ng, and any associated procurement of equipment
and materials for all approved plant emergency
modifications. The highest priorities were assigned
to those modifications necessary for the long termcooldown of the reactor system to cold shutdown
conditions, and for controlling and minimizing thereleases of radioactive gases and fluids to the environment. The PMG was divided into four organizations: engineering and design, procurement, construction, and special projects.
The directives for the PMG generally came fromthe Technical Working Group (TWG), which met
twice daily. Its members were the managers or theirdeputies of all groups of the TMI-2 Recovery Organization. The TWG received input from all
managers, evaluated proposed plans or analyses,
developed and agreed on the necessary criteria,
and then provided direction to the operating groups
to initiate the activities within their scope of responsibility. This procedure was not strictly adhered toat all times because of time limits. For example, theg. Summary of Findings andRecommendations
Findings• The industry support played a major role in as•

•

•
•

•

89 1

sisting the GPU organization to achieve safe
shutdown of the reactor and to mitigate theconsequences of the accident.
The TMI-2 emergency plan in effect on March
28, 1979, did not include provisions for technicalsupport for plant operations; the plan was limited
to the radiological response as required by the
NRC.
On March 28, Met Ed requested only limited assistance from its nuclear steam supply systemdesigner and manufacturer (B&W in Lynchburg,Va.) and did not, therefore, effectively use thetechnical expertise available.
Control room data indicating plant status were
not communicated to B&W in Lynchburg, Va., in ati mely manner on March 28.
B&W personnel in Lynchburg, Va., managed todiagnose the lack of adequate core cooling fromthe hot-leg temperature data. They were thenable to recommend actions to be taken to establi sh adequate core cooling.
The architect-engineer, Burns and Roe, provided
engineering expertise and information on theplant, which helped in the diagnosis of plant conditions.

shutdown status and to mitigate the consequences of the accident.

• Burns and Roe provided substantive support in

the engineering and construction of systems andequipment changes that were made to mitigate
the consequences of the accident.
• The manpower and technical expertise required
to cope with the accident exceeded those available from the Met Ed and GPUSC organizations.
• Earlier mobilization of the TMI-2 recovery effort
would have led to earlier assessments of plantconditions, development of corrective actions andplant modifications, and the achievement of plantstability.

• The fact that plant specific information was notreadily available at the site delayed technical personnel in their efforts to place the plant in safe

89 2

Recommendations• The NRC should require that the emergency

plans for all nuclear powerplants include provisions to assure prompt technical support to plant
operations personnel coping with a reactor accident and its consequences. Also, the NRC
should ensure that adequate technical andmanagerial personnel and resources will be requested and integrated into a preplanned emergency organization for response to and recovery
from an accident.
• The NRC should interact with nuclear industry organizations in defining the criteria and guidancefor emergency planning.

REFERENCES AND NOTES
1

22

Klingaman Interview Memo at 2-3.
Dieckamp dep. at 21.

Denton dep. (Oct. 4,1979) at 35-36.
Dieckamp dep. at 29.
24
Arnold dep. at 65.
25
Denton dep. (Oct. 4, 1979) at 38, 42-43.
26
Watson dep. at 104-105 (Pres. Com.).
27
Dieckamp dep. at 29.
28
Spangler dep. at 50-51. Exhibit $3104 at 1.
29
Arnold dep. at 18-24.
30Keaten dep. at 38.
31
Wilson Interview Memo at 10.
32
Deddens dep. at 28-39.
33
d. at 41.
34
Arnold dep. at 40-42.
35/d. at 60-68.
23

2

Wilson Interview on June 1, 1979 PE) at 23-24.
Arnold dep. at 66-67.
5Dieckamp dep. at 44.
8
Cherry Interview Memo at 1-4.
3
4

Keaton dep. at 73-75.
Owen Interview Memo at 6.
9
Id. at 5.
10
Lee Interview Memo at 1-2.
"Denton dep. (Oct. 4,1979) at 45-46.
12Dieckamp dep. at 40-41.
t3/d. at 35.
14/d. at 37.
'5/d. at 31-33.
16
Zebroski Interview Memo at 3-4.
17
Arnold dep. at 57-58.
18
Dieckamp dep. at 71-72.
1eArnold dep. at 54.
20
14. at 56.
7

8

36

Denton dep. (Oct 23, 1979) at 34-35, 44.
37 Arnold dep. at 64.

38

Dieckamp dep. at 39.
Cobean dep. at 8.
40
Id. at 27-31.
39

21

NRC Commission Meeting Transcripts (March 30,1979) at 209.

89 3

5. REPORTING CRITICAL INFORMATION TO
THE NRC ON MARCH 28, 1979

With respect to item 1, hot-leg temperatures, itappears that this information was available to NRC
i nspectors who arrived in the Unit 2 control room
about 11:00 a.m. on the morning of March 28, butthat there was a 3- to 5-hour delay before hot-leg
temperatures that clearly indicated saturation or superheat conditions reached offsite organizations.
For example, such hot-leg temperature readings
evidently did not reach B&W's engineering group in
Lynchburg, Va., until about 1:30 p.m. on March 28,
and were not reported to NRC's Bethesda Headquarters until about 12:30 p.m. It was after 2:00
p.m. before NRC response centers in Bethesda andthe Region 1 learned of temperatures indicating substantial superheat. There may also have been a del ay of several hours or more before GPUSC engineers in New Jersey learned of these temperatures.
Hot-leg temperatures well above saturation imply
that a substantial portion of the core is at least partially uncovered and is being cooled, if at all, bysteam rather than water. The elevated hot-leg temperatures were well known to control room personnel throughout the day and were generally perceived as indicative of a very serious problem in thereactor. However, if the full implications of thesetemperature readings were understood by those in
the control room, their conclusions were not comWhen
offsitemunicatedtotheoutside.
andorganizations-the
NRC,
B&W,
GPU
engineers-learned of the high hot-leg temperatures
i n midday and early afternoon, they did not immediately draw the conclusion that the core was or had
been uncovered; but individuals in each organization
eventually expressed strong concern about thatpossibility. Several B&W engineers convinced theirpeers that the reactor was in serious condition andthat high-pressure injection flow should be maintained. The NRC's Victor Stello, in a direct telephone conversation with the Unit 1 control room,
urged that consideration be given to whether thecore was uncovered. And GPU engineering officials
and their boss, Robert Arnold, became extremely
worried and eventually developed a strategy ofrepressurizing the reactor that brought core coolingback to stability on the evening of the first day.
The failure of control room personnel to communicate prompt and accurate information about
hot-leg temperatures, and to grasp their implications, certainly raises questions about their competence, a matter discussed in our overall conclusions. However, there does not appear to be a substantial question as to whether this information was
willfully withheld from the NRC.
With respect to items 2 and 3, however, precise
and accurate information does not appear to havea. Introduction and Summary of Conclusions

The severity of the Three Mile Island accident
was not generally recognized until the morning ofMarch 30, 2 days after the accident began andmore than 1 day after the reactor itself had beenbrought to a relatively stable condition. However,
i nformation available in the control room of thestricken reactor plant during the day of Wednesday,
March 28, clearly indicated that its core had been
uncovered for a substantial period and that its fuelrods were critically damaged.
The question has therefore been raised whether
such information was willfully withheld from the NRC
by Met Ed's employees or management in an attempt to minimize or coverup the seriousness of theaccident. Such an intentional failure to provide significant safety-related information by a licensee to
the NRC might, among other things, constitute a viol ation of NRC regulations and statutes.
The specific items of information involved are thefollowing:
1. Between 7:00 and 9:00 a.m. on March 28, personnel in the control room knew that temperatures in the reactor's "hot legs" (the piping
through which reactor coolant leaving the corefirst passes) were greater than 700°F, several
hundred degrees above normal. Through most of
the day, these temperatures were elevated to thisapproximate level. These temperatures are well
above the "saturation" point for the pressures atwhich the system was operating, indicating thatsuperheated steam had formed in this piping.
Continued elevation of hot-leg temperatures
should have led to a conclusion that bulk boiling
was occurring in the core area and that the core
was, or had been, at least partly uncovered.
2. By about 9:00 a.m. on March 28, electrical technicians had measured temperatures in the corearea, recorded by so- called "incore thermocouples," exceeding 2000°F. At least a few of thesereadings were reported to control room personnel.
3. At 1:50 p.m. on March 28, an instrument showing
reactor building pressure indicated a rapid pressure increase from 4 psig to about 28 psig andback again in a few seconds. This pressure"spike" was later diagnosed as having beencaused by burning of flammable hydrogen gas in
the reactor building produced by hightemperature decomposition of the reactor fuelrods' cladding or outer sheathing.

894

comprehensive reporting of such data by control
room personnel was never requested by Met Ed
management, the NRC, or B&W managers during
the day on March 28.

been communicated to responsible NRC officials.
Therefore, the Special Inquiry Group (SIG) undertook an intensive inquiry into how this information
was gathered, how it was interpreted, whether it
was given credence, and to whom it was reported.
The SIG also conducted an inquiry into whether
i nformation about certain early radioactive dose esti mates performed by Met Ed personnel (which
turned out to be inaccurate) was withheld from the
NRC. This information is the following:b. High Dose Rate Projections
Beginning at about 7:13 a.m. on Wednesday,
March 28, 1979, a lead encased ion chamber located in the upper region of the TMI-2 reactor building
signaled a 200-fold increase in radioactivity (to20000 R/h) over 5 minutes. This sudden, grosscontamination of the building's atmosphere apparently resulted from venting of highly radioactive
gases from the pressurizer steam space into theopen reactor building equipment drain tank.
Gross contamination of the reactor building atmosphere actuated visible and audible alarms in thecontrol room and caused Station Manager Gary
Miller to escalate the existing site emergency to a
general emergency. "General Emergency" is Met
Ed's most serious category of emergency and isreserved for plant conditions and accidents potentially dangerous to the general public. Miller's declaration of a general emergency at 7:24 a.m. initiated a cascade of actions by the plant staff to notify
State and Federal agencies of the general emergency, assess potential offsite radiological consequences, and establish communication links to keep
State officials informed of the radiological assessments.
The plant staff's initial step in assessing radiological consequences was to calculate potential offsite
dose rates in the downwind direction by using datafrom inplant instrumentation. Recognizing that thisfirst calculation was likely to be grossly
i naccurate-the amount of radioactivity escaping
from the plant into the atmosphere (defined as thesource term in the equation) was based on a set ofconservative assumptions, such as the amount ofleakage from the reactor building-plant personnel
performed actual measurements of the radioactivity
at outside locations to correct the assumed source
term. These actual offsite measurements would be
used by State officials to decide what offsite protective actions should be taken to protect the public.
Plant engineer Howard Crawford apparently
started the initial calculation of the potential offsite
dose rate around 7:18 a.m., shortly after the 200fold increase in radioactivity was detected. This
calculation predicted a whole-body exposure rate of
10 R/h at the "low population zone boundary" in the2
downwind location. At the time, there was wind of
4 miles per hour blowing towards Goldsboro, a

4. Prior to 7:30 a.m., a control room meter andrecorder signaled that radiation dose rates in theupper part of the reactor building increased
200-fold, to 20000 R/h, over 5 minutes. Fromthese readings, control room personnel calculated a potential radiation dose rate of 10 R/h at thewest side of the site boundary, in the direction ofGoldsboro, Pa.

Our factual findings with respect to items 2, 3,
and 4 are discussed in detail below.
Our overall conclusion is that the evidence fails
to establish that Met Ed management or other personnel willfully withheld information from the NRC.
There is no question that plant information conveyed from the control room to offsite organizations
throughout the day was incomplete, in some instances delayed and often colored by individual interpretations of plant status. Indeed, information
conveyed by Met Ed, NRC, and B&W employees in
the control room to their own managements andoffsite organizations was in many cases incomplete
and even inaccurate. However, we did not develop
evidence to show that the causes of this breakdown
i n information flow went beyond confusion, poor
communications, and a failure by those in the control room, including NRC and B&W employees, tocomprehend or interpret the available information, afailing shared to some extent by offsite organizations as well.
A few individuals, both on site and off site, madestatements and/or believed at some point on March
28, that the core had been uncovered, but the evidence does not indicate that anyone had a reasonable understanding of the severity of the accident
until the night of March 29 at the very earliest. Thismisunderstanding appears to have been caused primarily by incomplete information available to any
one particular individual or group about the trend ofcritical plant parameters (such as temperatures andpressures) over the course of the accident. Significantly, other parts of our investigation have shownthat control room personnel were unwilling or unable
to focus on reconstructing such information in thecourse of coping with the ongoing accident, and that89 5community of 576 persons located 1.4 miles due
west of the site. The calculation was checked by
Richard Dubiel, Supervisor of Radiation Protection
and Chemistry, who then promptly advised Thomas
Gerusky, Director of the Pennsylvania Bureau of
Radiation Protection, of the prediction.
Although the predicted dose rate was believed to
be much too high, Gerusky instructed Margaret
Reilly, Chief of Environmental Radiation Division, tonotify the Pennsylvania Emergency Management
Agency (PEMA). At 7:45 a.m., Reilly notified Kenneth Lamison, PEMA Operations Chief, to makepreparations for possible evacuation of people fromnearby Brunner Island and Goldsboro because of
the predicted 10-R/h dose rate. At 8:15 a.m., Reilly
advised the PEMA office that there were no outside
releases detected and advised that the imposed
evacuation alert be discontinued. Reilly's information came from Dubiel at the plant who, by that time,
had received results of the initial outside radiation
surveys.
A survey taken at 7:45 a.m. near the plant boundary immediately west of the reactor building revealed radiation levels less than 0.001 R/h. Thissurvey confirmed that the significant offsite radiation
l evels calculated earlier, 10 R/h, did not exist.
The fact that NRC officials were not specificallyaware of the initial offsite prediction of 10 R/h has
raised the question whether Met Ed personnel intentionally withheld important information from the
NRC that would have demonstrated that the accident was much more serious than was generally
thought on Wednesday or Thursday. The evidence
relative to this matter is set forth in the following
paragraphs.
Miller took charge of the TMI-2 control room at
7:05 a.m. on March 28, 1979. About 10 minutes
later the first strong indication of the seriousness of
the TMI accident surfaced when the radioactivity
levels in the reactor building dome increased 200fold. Review of the chart from control room recorder HP-UR-1901 shows that this increase occurred
after 7:00 a.m. and took place over 5 minutes. This
rapid contamination of the reactor building's atmosphere was connected with a release of fission
gases from the reactor coolant system. This statement is supported by other plant data that showthat the block valve used to isolate the pressurizer
pilot-operated relief valve (PORV) was reopened at
7:13 a.m. for 3 minutes after being closed since 6:18
a.m.
Opening this valve vented the pressurizer to thereactor building atmosphere via the stuck-open relief valve and through the open rupture disc on thereactor building drain tank. The recorder chart
further shows that the 8-R/h trip level set on the
89 6control room meter for containment dome radiation
monitor HP-R-214 was exceeded during the sudden200-fold increase in radioactivity. Since Miller declared a site emergency at 7:24 a.m. based on themeter reading for HP-R-214 exceeding 8 R/h, andthe pressurizer PORV block valve was reopened for
3 minutes beginning at 7:13 a.m., it is reasonable tofix the time of gross contamination of the reactor
building atmosphere between 7:13 and 7:18 a.m. on
March 28, 1979. The recorder chart also indicatesthat the radiation monitor HP-R-214 meanderedaround the 200-R/h reading throughout the morni ng. Because the HP-R-214 detector is an ion
chamber encased in 2 inches of lead, plant procedures assume an attenuation factor of 100, hence,the 200-R/h meter reading is assumed equivalent
to 20000 R/h at the detector location. (Information
developed after the accident indicates that the leadencasement design contains a weep hole permitting
direct access of gases to the sealed ion chamber.
This hole decreases the attenuation factor.)
I nitial calculation of the projected offsite dose
rates was completed by Crawford sometime after
the 200-fold increase of radioactivity in the reactor
building's atmosphere. I n disputed testimony,
Crawford's recollection was that he performed thecalculation on the basis of an HP-R-214 meter readi ng taken between 6:55 and 7:10 a.m. on March 28,
and this calculation predicted a dose rate of 40 R/h
at location code "W-11" (Goldsboro). 3 However, nodocumentation, such as a calculation data sheet,supports his recollection. Crawford has also said
that when the site emergency was declared at 6:55
a.m., he was lined up at the processing center outside the plant and subsequently went to the Unit 2
control room, obtained reference material, and set
4
up a work place to perform his calculation. It took
Crawford several minutes to finish the preparations
before beginning his calculations.
On the other hand, Dubiel, whom Crawford
agreed was the one who checked his calculations,recalled that the projected offsite dose rate was 10
R/h and that this calculation was completed around
7:35 a.m. 5 Miller also does not recall a 40-R/h projection; rather, 10 R/h. 6
Although the discrepancy is not critically significant to the question of withholding of information,
there has been some confusion as to whether the
projection was 10 or 40 R/h. Convincing evidence
suggests that Dubiel's recollection is more accurate
than Crawford's. In addition to fixing the time of the
200-fold increase in radioactivity in the reactor
building to the period 7:13 to 7:18 a.m., offsite dose
calculation sheets completed by Crawford on March
28 were available and were reviewed. Of these, theearliest has a time of 7:44 a.m. and has a calcula-tion for the low population zone boundary towards
Goldsboro using an HP-R-214 reading of 300 R/h.
It is apparent from the calculation sheet that thecalculation was first completed using 2 miles perhour as the wind speed, and resulted in a calculated
dose rate of 20 R/h. Then, the wind speed waschanged to 4 miles per hour, which halved the projected dose rate to 10 R/h. Crawford thenapparently marked over the 2 with a 1, resulting in acharacter that can easily be mistaken for a 4. The
result of this calculation sheet was then transferred
to an offsite code calculation log andthereon was
7entered 40 R/h instead of 10 R/h. ( As previously
stated, the 40 vs. 10 R/h is of limited interest to thei ssue at hand. Our review was merely to clear therecord on this and to clarify that, contrary to statements appearing in the NRC's Office of Inspection
and Enforcement's investigation report on theaccident, it appears that Crawford correctly readthe control room meter and correctly applied thespecified methodology during his calculations.)
The evidence indicates that the initial calculationof offsite dose rate was performed simultaneouslywith notifications to State and Federal agencies
about the site and later the general emergency, andconcurrent with the confirmatory radiation surveys
at the west side site boundary. Gerusky of theState was informed of the projected dose rate at
7:35 a.m., which appears to be about the time that
Crawford completed the calculation. State officials
are responsible for determining and initiating actions
for protecting the public, and Dubiel and Crawford
evidently did the best they could in assessing andi nforming the State of the projected high dose rate
at Goldsboro. Reilly of the State, in response to aquestion on whether Met Ed met its agreementswith the State in terms of providing information andproviding assistance, said, "I really don't have any
great complaints with them. I think, in essence, they
upheld their end of the bargain." 8 Reilly also said
she thought Met Ed "told us what they thought was
8going on at the time."
No documentation indicated that the NRC was
notified. Transcripts of the March 28 telephone
conversations that were tape recorded show thatafter Met Ed established communications with NRC
Region I around 8:00 a.m., Met Ed personnel maintained continuous contact with Region I and were
responsive in providing information. 9 Also, Met Ed
dispatched an onsite survey team at 7:28 a.m. andhad confirmatory radiation survey data by 7:45 a.m.
that showed that 10 R/h at Goldsboro could notexist. Furthermore, by 7:50 a.m., offsite dose calculations using a revised source term were completed,projecting dose rates of less than 0.001 R/h atGoldsboro. Surveys conducted by Met Ed person-

nel in Goldsboro at 8:32 a.m. confirmed this projection.
I n reviewing the NRC Region I accident message
forms completed on March 28 and the transcripts of
taped conversations between Met Ed and Region I,
it appears that Dubiel and George Kunder, Superintendent of Technical Support, made the NRC awareof the high levels of radiation in the reactor building
as indicated by the containment dome monitor.
Dubiel and Kunder doubted that the radiation levels
were as high as indicated-stating that they
believed the steam environment existing in the containment affected the accuracy of the instrument.
They were not alone in this belief; Bob Arnold, Vice
President of Generation, GPUSC, in discussing his
recollection of the 8:30 a.m. telephone call with Jack
Herbein, Vice President of Generation, Met Ed, on
March 28 stated:
I think we talked to some extent about what they
had seen on the radiation monitors-more specifically, the dome monitor ... I know that my tendency was to think that moisture in the containmentbuilding had probably given us failure of the instrument ... 0

The telephone transcripts also show that at
about 8:00 p.m. on March 28, Ronald Nimitz, NRC
Region I Inspector, speaking from the control room
at TMI to Lee Thonus, an inspector at the Region I
I ncident Response Center, had the following conversation:
Nimitz: Now then, one's [Area Radiation Monitor) in
the reactor building dome, it's an ion chamberapparently, it's right in the dome of the reactor[ building]-and it's got a lead sheet in front of it; thefactor reduction in the activity of about 100-thedose rates from the dome area.
Thonus: We're familiar with that.
Nimitz: Okay, they're saying that thing's reading
20 000 R per hour.
Thonus: Afteryou take the 100 into account?
1
Nimitz: Yes. n

At 9:55 a.m. on March 29, when senior NRC staff
briefed the assembled Commissioners in their
Washington office, it was noted that the radiation
exposure levels measured were recognized as signsof fuel failure, but the staff believed the very highl evels measured in the reactor building dome were
erroneously high.
Our analysis of the foregoing is that the licensee
did not willfully withhold meaningful information fromthe NRC concerning high dose rate projections or
the high levels of contamination inside the reactor
building. The NRC was aware of the dome monitor
i ndication showing dose rates as high as 20000
R/h in the reactor building. NRC discounted thisi nformation.
89 7

Met Ed personnel promptly informed Stateauthorities of the 10 R/h projected dose rate. We
found no reason why Met Ed would purposefully
withhold this information from the NRC. Telephone
contact from Met Ed to NRC authorities wasdelayed until about 7:45 a.m. (NRC Region I
answering service took calls from Met Ed at 7:04
and 7:40 a.m.). At about this time, Met Ed confirmed that the projected offsite dose rate of 10 R/h
could not exist and by 7:50 a.m. had made a new
projection of less than 0.001 R/h. Probably for thisreason the 10 R/h was not discussed at any greatl ength with the NRC, if discussed at all. Moreover,transcripts of tape recorded telephone conversations between the TMI control rooms and NRC showthat the Met Ed personnel provided prompt andaccurate answers to NRC questions about outsideradiation levels and reactor building dome monitor
readings throughout the day on March 28.

that the incore thermocouples were not speciallytested and "qualified" as instruments upon which it
was assumed operators would rely in the case of an
accident, but he was familiar with them from his experience on naval reactors. 13
When Porter went to the computer terminal and"called up" a series of readings he found that, formany of the thermocouples, the computer printed
out question marks rather than numbers. This effect indicated either that the instrument was malfunctioning or that it was giving a reading off thenormal computer scale.
Porter reported thisphenomenon to Miller, who asked him whether there
was any other way to read the instruments. Porter
replied that he thought readings could be taken off
the wires tothe computer console, by hand-held in14,15
struments.
Porter then recruited an instrument foreman, Nelson ("Skip") Bennett, and two instrument technicians, Thomas Wright and Roy Yeager. After locati ng some meters and drawings necessary to locate
the correct wires, all four proceeded to a room
directly below the computer on the floor underneaththe control room.
According to Porter, after he had helped the other men locate the correct electrical cabinet and instructed them to try to determine from the voltagesi n the wires what temperatures were being measured by the thermocouples, he went upstairs to thecontrol room, andthen came back downstairs a few
16,17,18
I n the meantime, the otherminutes later.
three men (apparently assisted by another foreman,
Bob Gilbert) unscrewed the leads on several sets ofwires and attachedthem across a Fluke digital ther16,17
This meter converts voltages
mocouple meter.
to temperature equivalents and actually reads out
the temperatures being measured by the thermocouples. However, it requires that the computer
wires be detached from inside the cabinet and attached to the meter, so taking readings was a fairly
cumbersome process.
Porter recalls that when he returned downstairs,
the technicians reported to him that they had taken
about five readings. Two readings were about
2300°F-far in excess of "normal" readings in the
500° to 600°F range-and, Porter recalls, one or
two readings were about 200°F, which would bemuch lower than anticipated even under normal
cooldown circumstances. According to Porter, hethen went back upstairs to the control
room and re17.19
ported these readings to Miller.
In an interview of Porter by NRC's IE investigators on May 21, 1979, Porter recalled that Miller,
upon hearing the numbers Porter related to him,
asked what these readings meant. Porter did notrecall precisely what he had answered, but remem-c. Incore Thermocouple Temperature
Readings

Ivan Porter, Unit 2's Instrumentation Control Engineer, arrived in the control room about 6:30 a.m.
and was told by Kunder that according to the instrumentation, hot-leg temperatures were off-scalehigh, system pressure was about 700 psi, and all
the reactor coolant pumps were off. Because thetemperature and pressure readings seemedanomalous to Porter, he attempted to verify thereadings from "redundant instrumentation." Having
done so, Porter reported to Kunder that he thought
the instruments were reading properly. Next, Porterset out to get an actual reading of hot-leg temperatures by setting up a Fluke digital voltmeter acrossthe wires leading into the computer console fromthe A loop hot-leg temperature detector, a resistance temperature detector (RTD). Extrapolatingfrom the voltage reading he obtained, Porter concluded that the actual temperature in the A hot leg
was about 715° to 721°F. Porter recalls reporting
this information to Miller, Station Manager, and Mike
Ross, Supervisor of Operations
12 for Unit 1, some time
between 7:00 and 8:00 a.m.
At about this time, Miller asked Porter to "punchout" on the computer, temperature readings fromthe incore thermocouples. (Actually, the adjective"incore" is something of a misnomer, because thethermocouples are located just above the fuel elements, on the metal assemblies that hold the fuelrods in place. Thus, they measure the temperaturesof the coolant water as it flows out of the core.)
These instruments were not part of the regular instrumentation for TMI-2, as they are in some otherreactors, but were placed in the reactor vessel aspart of the startup and testing program. Miller knew898

bered that his evaluation was that the thermocouples might have been destroyed or damaged. Porter stated that he knew the 200°F readings could not
be correct-especially inasmuch as the hot-leg
temperatures were around 700°F, far above
normal-so he had no reason to believe that thehigh temperature readings were accurate either. 20
I n a later IE interview, Porter reiterated that he did
not really believe the high readings. And in a deposition conducted by the Special Inquiry Group, Porter testified:li eve the readings, ... and says, 'I don't believe yourreadings.'" 25 He also recalled that they confirmed
these readings with a second instrument-a
voltmeter-before Porter left.

I believe Ivan didn't want to believe what was taking
place. I don't know whether it was an attitude of' Hey, your measurements are wrong-you guys
don't know what the heck you're doing'-or whatnot. I think the general consensus throughout thewhole first day was, number one, nobody reallyknew what was actually happening, number two,some that had an inkling of what was happening
didn't really want to believe what was going on. 28' 27

I continue to be amazed that everybody thinks that
we should have placed 100 percent reliance on
2300 and tossed out 220 ... we went down andtook three or four readings and they were just highand low and every place, just like what the computer said, so we went on to something else. 21

Wright also recalled to the IE investigators thatafter the technicians had taken about five readings,
one or two of which were around 200°F and one or
two around 2100°F, Porter appeared on the scene,
and that Porter's response was that "the data didn't
look too good." 28 Wright recalled that Porter said,"There's some there that are, that look too high ...
that look like they'd been damaged." 29 Wright also
remembered Yeager saying to Porter that the core
was uncovered. 30
Skip Bennett also told IE interviewers that he believed the subject of the core being uncoveredcame up in Porter's presence: he recalled that"they" made a statement to Porter that the corepossibly had been uncovered. 31 Wright also statedthat it was his personal view that while the hightemperature readings could have been inaccurate, it
was more likely that the core had been uncovered
and then recovered, and that the temperatures werevery slow in coming down. 32 Bennett said to the interviewers that he recalled "concern or disbelief" at
the high readings, but that at the same time it was
his feeling that Porter himself was "more or less inagreement" with everyone else about the possibilityof core uncovering. 33
Porter testified that he does not recall any discussion with the foremen and instrument technicians about the core possibly being or having been
uncovered, but admits that it is possible that such acomment was made to him. 34 In a deposition takenby the SIG, Porter testified that he himself did notthink that the incore thermocouple readings showedthat the core had been uncovered. 35 At the sameti me, however, he said that he was very concerned
about the hot-leg temperatures. And, in a previous
I E review, when asked what his reaction had been
to the 2300°F reading(s),Porter replied, "I guess I
36
was afraid it was real."
In the deposition of Porter by the SIG, he pointed
out that he expected to see abnormally high incore
temperatures on account of the high temperatures
i n the hot legs. But he maintained that he did not
expect to see temperatures in the vicinity of 2000°F
and above; and he consistently maintained that, be-A written statement prepared in April 1979 byGary Miller and others in the control room on March
28 related that "the readings we got back from thepenetration varied from 200° to 2400° to nothing,"
and that Miller did not have confidence in theiraccuracy (pp. 17-18). Miller and Porter discussed
possible causes of inaccurate readings, and Porter
explained that the thermocouples or lead wires tothem might have melted, causing junctions to fuse
together and produce erroneous voltage readings.
The "technical explanation," Miller said, was that thethermocouples were clearly "hot," 22
which indicatedhigh temperatures in the core area.
Porter said in
an IE interview that he did not specifically recall discussing with Miller whether junctions might havemelted, but agreed they may have discussed whatmight affect the readings.48

In any event, as Miller recalls it, Porter related
only four or five readings to him, they had one shortconversation, and Miller accepted Porter's evaluation that the readings were inaccurate without any
22
Thereafter, according todetailed questioning of it.
both Miller and Porter, little or no attention was devoted to the matter. Porter does not recall discussi ng the readings with anyone else, though he cannot
23
and Miller
rule out the possibility that he did,
thinks that while some other people probably were
aware of the readings from overhearing his conversation withPorter, there was no further discussion
24of them.
Three of the men present during the time when
the first readings referred to above were taken off
the wires told IE interviewers that they recalled acomment being made in Porter's presence about thehigh temperature readings indicating that the core
was or had been uncovered. Yeager recalled thatafter taking some initial readings, he turned aroundand told Porter that "the core is uncovered. Okay,
Mr. Porter kind of doubted our word and didn't be-

89 9

cause he firmly believed that the low temperature
readings were clearly wrong, he had no reason tobelieve that the high temperature readings were in
the right ballpark either. 37
I n any event, both Porter and Miller agree that
there was no discussion between them of whether
the high readings might mean that the core was uncovered or had recently been uncovered. 38,39-40
Their conversation was limited, according to thesubstance of their testimony, to the fact that thereadings were not regarded by Porter as reliable
and to the reasons why the wires from the thermocouples might be giving off such unreliable readings.
When questioned as to whether discussion about
the possibility that thermocouples or lead wires had
melted would not have suggested a conclusion thatthe core was uncovered, regardless of the accuracyof the temperature readings, both Porter and Miller
have maintained that they did not reach such a conclusion during the morning of March 28.
After Porter returned to the control room to brief
Miller on the first four or five readings, the instrument technicians took a separate instrument calleda digital voltmeter (which can be used to give voltage readings from incoming wires without detaching the wires and hooking them up to the meter itself) and used it to record voltage readings for atleast 40 of the approximately 50 thermocouples.
Using tables, these voltage readings could be extrapolated to give temperature readings. The voltage
readings indicated that about 18 of the thermocouple leads showed temperatures above 1500°F scattered throughout the core in no particularly discernible pattern. Others were inexplicably low, in the
200° and 300°F range. These voltage readings
were handwritten in a computer book by Bennett.
The instrument technicians and foremen then returned to the control room where41,42
Bennett set thebook on a console and left it there.
These additional readings might have tended toconfirm the validity of the higher temperature indications. However, Porter has testified that he did notl ook at them, and did not become aware of them
until much later. 43 Porter testified that he probably
knew that the instrument technicians were going tocontinue to take readings with a millivoltmeter, but
he did not believe they were going to get useful information, and did not look in the43,44
computer book to
see what they had come up with.
Shortly thereafter, all of the other men involved,
i ncluding Bennett and the instrument technicians,
evacuated Unit 2 when increasing radiation levels in
the control room caused a general order fornonessential personnel to leave the area.
One other issue concerning these readings has
been the subject of some prior comment. Two of

the four technicians and foreman present when thefirst readings were taken recalled in interviews by IE
i nvestigators that a few sets of wires indicated temperatures higher than 2100° to 2300°F. Wright told
the IE investigators that when the technicians firststarted to take a complete set of readings with themillivoltmeter, one or two were up around 75 millivolts, corresponding to 4000°F. 45 Yeager recalledthat at the very beginning, before Porter arrived, anumber of preliminary readings were taken with themillivoltmeter and that the 46
range was from about
690° up to 3700° or 4000°F.
Porter consistently maintained that he was nottold of any readings above about 2300°F, which isthe number he related to Miller. 47 Such readings
would have been spurious, since the chromel-alumel
alloy of which the thermocouples are constructed
melts at about 2700°F. (In subsequent days andweeks, almost all of the thermocouples recorded
48
readings indicating that they were functional.)
Porter pointed out in the deposition conductedwith him by the SIG, that the conversion charts formillivolts to temperature stop at the voltage
corresponding to 2500°F, and that a further
straightline correlation would not necessarily be accurate, so that it is unlikely that an instrument technician could compute a 3700°F reading; and that atest he conducted of the Fluke digital instrumentthat reads out directly in degrees showed that itstops 49
recording and starts "blinking" above
2462°F.
Perhaps more significant, the pages from thecomputer book in which the complete set of millivolt
readings were entered does not show any suchhigh readings. Indeed, the highest is about 56 mV,
corresponding roughly to 2580°F. Thus, no readings of 3700° to 4000°F were recorded when acomprehensive reading of all the terminals was conducted after Porter left for the control room.
The significance of the difference between 2300°
and 3700°F appears to be that if the temperature in
the core were in fact the higher number, one would
know that the core was probably actually melting
down. Porter's response and the response of others to this suggestion has been that since such a
reading, in millivolts or on a Fluke digital reader,
could not possibly have been regarded as reliable inany way, it would have been an even less significant
i ndicator of trouble than a 2300° or 2500°F reading.
I n the final analysis, we do not believe that the issue is a meaningful one. It is possible that initial millivoltmeter readings of about 75 mV were obtained,
but it seems unlikely that they were communicatedto Porter; if they were, it appears he discounted
them out of hand. The important point is that eventhe 2300°F readings everyone acknowledges were900

apparently, the very high numbers measured by thetechnicians that morning were not transmittedeven though the information was sitting in a computer book on one of the control room consoles.
I ncident Response Center tapes indicate that
NRC Headquarters asked for readings from the"thermocouples on the fuel assembly outlet" probably in the late morning. 52 During another conversation in midafternoon with the Unit 1 control room,an NRC employee noted that the information had
been requested previously, "and I don't know if weever got an answer back." 53 Greg Hitz, a Met Ed
shift supervisor in the Unit 1 control room, is recorded on the tape as agreeing to try to get the information. Shortly after, Hitz reported that he could not
get exact numbers because the computer was
printing out question marks. 54
Hitz recalled the following in a deposition takenby the Special Inquiry Group:

obtained would have been enough to suggest aseverely overheated core, if they had been believed.
Porter's testimony was that he did not believe them,and so reported to Miller. Miller corroborates that
account.
Did Porter or Miller have an affirmative obligation
to report these readings to the NRC on the 28th? It
would appear that if either man had such an obligation it was probably Miller: Porter had, after all, reported the information he had gleaned to the station
manager and received no further instructions. Miller, on the other hand, has said that what he learned
from Porter, together with his knowledge that thesei nstruments were not "qualified" to withstand abnormal conditions, convinced him that he should notplace any faith in the readings and that he thereafter
gave them little thought:

I n other words, the unreliability part of it, my lack ofusage or training in them didn't make them something that I needed. They weren't recognized anywhere other than in my mind from past experience.
I just think that all came together in my mind tocause me not to go back and ask a lot of questions
that I could ask today quite honestly. I think thatcombined with the number of events I was involved
i n in that next three to four hours caused me not togo back and ask some more questions and put adifferent emphasis on the readings.50

The large range or spectrum in temperatures theylooked at the in-core temperatures which ranged
from 60 degrees to 1400 degrees. You look at thatwhole thing and say do I really believe this or not?
. .. I don't think that I paid particular attention to thein-cores because of what I was involved with. I
would take the number and run it in and say they
are reading55
this or that. I may have looked at thein-cores ...

Miller's own testimony under oath, therefore, if taken at face value, rebuts any inferences of willful
withholding of information. Moreover, Miller's testi mony is substantially corroborated by Porter's testi mony.
Miller probably informed his superior, Jack Herbein, of the thermocouple readings, at least in a
general way, sometime in the late morning of the
28th after Herbein arrived at the Observation Center
across the river from the island. Herbein testified
that he believed he had been told that readings had
been taken and high numbers obtained, but thatthese were discounted. 51 Herbein's testimony,
therefore, further corroborates Miller's account.
Herbein himself, significantly, was not directly incontact with the NRC on the 28th. Moreover, atabout the same time he arrived at the site, NRC inspectors were going on site into each control roomand manning direct telephone lines from the control
rooms to NRC Region I's Incident Response Center.
Thus, between Miller and Herbein, it is reasonable topostulate that any direct responsibility for reporting
critical plant information to the NRC evolved upon
the former, rather than the latter.
Information that the incore thermocouples were
off scale on the high end was apparently available to
NRC inspectors in the Unit 2 control room, but
probably was not transmitted to NRC Headquarters
until at least midafternoon on the 28th. Even then,Victor Stello, in the Incident Response Center at
Bethesda, recalled in deposition testimony "struggling" to try to get information about the incore thermocouple readings. 58 Stello has also testified that
he recalled learning at some time on Wednesdaythat "the in-core thermocouples were reading question marks, which means they were reading off therange of high scale." Stello testified that he recognized that the thermocouples were therefore "broken" or that they were reading temperatures above
57
700°F.
Miller, who had been gone from the control room
between about 2:00 and 4:30 p.m. to brief the Lieutenant Governor at the Capitol in Harrisburg, had
not conveyed the earlier high instrument readingson the incore thermocouples to others in the Unit 2
control room with whom Greg Hitz, in Unit 1, wascommunicating to get information being requested
by NRC officials in Bethesda. There is no indicationthat NRC inspectors in Unit 2, who were in contact
withRegion 1's
Incident Response Center
throughout much of the afternoon, were specificallyrequestedby their management to obtain this infor58
mation.
Significantly, Stello was able to conclude from theelevated hot-leg temperatures alone, that the reactor was probably in a serious condition involving
bulk boiling in the core and possible core uncovery,90 1

as tapes of another conversation he had with Hitz
about 4:00 p.m. that afternoon reveal. Porter's testi mony that he too was primarily concerned about
the high hot-leg temperatures suggests a similar attitude on his part. In other words, the fact that superheated steam bubbles had continued to exist in
the hot legs for many hours should have been sufficient, by itself, to reveal that the core was extremely
hot and might be partially uncovered. Nonetheless,the fact that incore thermocouple temperatures
above 2000°F had been measured earlier thatmorning (if believed and accurately reported) would
clearly have been corroborative of the serious nature of the accident.
I n sum, the evidence indicates that only some of
the actual readings taken by instrument technicians
between 8:00 and 9:00 a.m. that morning were actually communicated to their supervisor, the instrumentation control foreman; and that neither he, thestation manager to whom he reported the readings
he had learned about, nor the vice president of Met
Ed credited the readings as being accurate. It is notclear that any of the actual readings were communicated to the NRC on March 28, despite requests forsuch information, although the general range ofreadings may have been transmitted. Clearly, however, NRC officials in Bethesda learned some time in
the afternoon of March 28 that the readings were
off-scale high, that is, above 700°F, which was in itself significant information. Even this information,
however, was delayed in transmission to the NRC.
Although it seems obvious that reporting of accurate information about the early morning readings
would have given significant corroborative evidence
about the seriousness of the accident, no evidencei ndicates that failure to report those readings was
willful or was part of any attempt to hide the condition of the reactor or the seriousness of the accident from the NRC.

tem in the reactor building that is triggered automatically (when containment pressure reaches a nominal pressure of 30 psig) came on. Several individuals in the control room heard a sound they later
described as "thud."At the time, little attention apparently was paid tothis "pressure spike." Because the volume of thecontainment building is so large, many of those in
the control room evidently could imagine no credible
phenomenon that would have produced such al arge pressure increase in so short a time. Somewrote off the instrument reading in their minds ashaving probably been caused by a stray electricalpulse or "transient" in the electrical wiring, rather
than by an actual pressure surge in the reactor
building.
When company employees examined the graphof the pressure spike late Thursday night in the lightof evidence that had been collected earlier that day(including a reactor coolant sample that showedmassive amounts of radioactive material in the
coolant water), they realized that an explosion of
flammable hydrogen gas must have taken place inthe reactor building Wednesday afternoon. 59,60
Key GPU officials and NRC personnel learned of
the spike and its significance early Friday morning.
The large amounts of hydrogen necessary to support such an explosion or "burn" could only havecome from chemical decomposition at very hightemperatures of a substantial amount of the reactor"cladding"-the protective outer sheathing of thefuel elements that surrounds and encloses theuranium fuel pellets. The cladding is made of a metal called Zircaloy-4, an alloy containing about 96%
zirconium, which reacts rapidly with steam at temperatures above 2200°F to produce hydrogen gas.
The gas, in turn, escaped from the reactor coolant
system into the reactor building through the stuckopen PORV when the block valve behind the PORV
was periodically opened to relieve overpressure in
the reactor coolant system Wednesday morning,
and again after 11:30 a.m. when the block valve was
opened for long periods of time to depressurize thesystem.
Had the pressure spike been recognized as a hydrogen explosion early Wednesday afternoon, it
would clearly have demonstrated that the reactor
core was uncovered or had been uncovered for al ong period of time. Moreover, the fact that temperatures high enough to produce zirconium-water
reaction had been sustained in the reactor core forsufficiently long to create the amount of hydrogennecessary to cause such an explosion would havesignalled that the core had been very close to apossible meltdown or had indeed experienced significant melting.

d. The Pressure SpikeAt about 1:50 p.m. on Wednesday, March 28,
1979, a control room instrument that displays reactor containment building pressure indicated a sudden, short-lived but dramatic pressure increase in
the reactor building. As an operator and at least
two supervisors standing at the consoles watched,
the pen-recorder on the instrument-which traces
the level of building pressure on a slowly moving
drum of graph paper with a scale from 0 to 80
pounds per square inch gauge (psig)-jumped almost straight up to about 28 psig then slowly fellback over the next 15 seconds to about 4 psig. At
the same time, a sodium hydroxide "sprinkler" sys90 2

The fact that neither the existence of the spikenor its significance came to the attention of responsible NRC officials until Friday morning has raised
the question whether Met Ed personnel intentionallywithheld important information from the NRC thatwould have demonstrated that the accident wasmuch more serious than was generally thought on
Wednesday and Thursday. The evidence relative tothis matter, including testimony which in somerespects is inconsistent, follows.
When the pressure spike occurred, Station
Manager Miller was in charge of the control room.
At that time, Miller was preparing to leave Three
Mile Island to brief Lt. Gov. Scranton at the Capitol
i n Harrisburg, approximately 25 minutes away bycar. Miller would be accompanied by George
Kunder, the Superintendent of Technical Support for
Unit 2, who was also in or near the control room at
1:50 p.m. Miller's "deputy" in the control room
( whom he left in charge of the plant when hedeparted for Harrisburg a few minutes later) was
61
Also in
Joe Logan, the Superintendent for Unit 2.
the control room area were at least three shift supervisors: Bill Zewe, who had been on shift at 4:00
a.m. when the accident began and remained
throughout the day; Brian Mehler, who had arrived
at about 6:00 a.m. in anticipation of taking over thenormal 7:00 a.m. shift; and Joe Chwastyk, who had
assumed responsibility for transmitting operating instructions to the control room operators at about
11:00 a.m. that morning, and was therefore directly"in charge" of the control room consoles. Also inthe control room area were Mike Ross, the Supervisor of Operations for Unit 1, who was in charge of
operations at the control room (Joe Logan was relatively the least experienced in the operating characteristics of the Unit, among the "management group"
present)62 and Lee Rogers, the B&W site representative. Logan, Ross, and Rogers had been present
since early that morning.
Zewe has testified that he was standing directly
behind the instrument panel, that he saw the spike"first," and that "everybody there" saw the spike.
He recalls discussing with others, among them Ross
and Chwastyk, what could have caused the spikeand whether the instrument had registered an actualpressure excursion in the building or had malfunctioned. He recalls specifically some discussion ofwhether a stray electrical impulse in the circuitry
might have caused the instrument indication. "Nobody," he recalled, "had good answers," and it was
eventually concluded that an electrical transient in
the circuit rather than actual pressure increase must63
have caused the pen-recorder's movement.
Zewe also recalls observing that the sodium hydroxide spray activated and shortly thereafter wasordered turned off when it became clear that thepressure increase, if any, had subsided. Significantl y, Zewe does not recall discussing the pressure
spike with, or even mentioning its existence to Gary
Miller .
Zewe's testimony is corroborated by Mike Ross,
who testified that although he did not personally observe the spike as it occurred, his attention was
called to it by a report that the building spray pumps
had gone on. 65 Ross recalls discussing the spikewith Zewe and concluding that it had been causedby an electrical spike in the circuitry, not by an actual pressure increase in the building. Ross recalled the following:
There were many people there, and it was common
knowledge that it happened, but I don't think anybody ever sat down and analyzed it at the time ... I
think we reached a hurried conclusion saying that
we thought the spike was caused by either a malfunction of some kind, and we just went on taking
care of business ... 67

John Flint, a B&W engineer who had also been in
the control room since early morning (and who, incidentally, testified in a deposition before thePresident's Commission that he personally had concluded in midmorning that the core had been uncovered), 68 said in an interview with a Met Ed investigator on April 20, 1979, that he was aware of thehigh pressure indication and the spray pump actuation, "and about the same time there was a double
thud." Flint also stated the following:
I personally did not think it was from the reactor
containment building. I thought that it was the ventilation dampers cycling. It was very close to thatsound, and since we had been in and out of
respirators due to the levels in the control building, I
just thought somebody had cycled the ventilation
dampers again and related it to that 69

Joe Chwastyk, who was in the control room
along with Zewe and observed the pressure spikeas it occurred, also recalls that there was a "lot of
conversation" about the spike and that "it immediately came to mind that we had some kind of instrument problem." 70 However, unlike the others,
Chwastyk soon concluded that the spike could nothave been caused by a stray electrical pulse because the spray pumps had come on and "there are
two different pressure instruments used, one for therecorder and one for starting the pumps." 71 I n otherwords, the fact that the reactor building spraypumps had been activated confirmed that an independent instrument had also detected a pressure
surge in the reactor building.
Brian Mehler remembers coming out of the shift
supervisor's office when he saw activity in the control room indicating that "an ES" (an activation of903

safety systems) had occurred, and observing thepressure spike trace. He too first "thought it could
have been an electrical thing. But then looking at
the spray pumps, I realized it couldn't have been." 72
I n fact, as Mehler recalls explaining to an NRC inspector who was present, the reason the actuationof the spray pumps tended to rule out an electricaltransient as the cause of the pressure spike was
essentially the same reason suggested by Chwastyk in his deposition. Mehler recognized that it wasthe "coincident logic" arrangement of the circuitry
for the spray pump system that made such a possibility highly unlikely. There are three sensors in thereactor building that record building pressure. To
reduce the possibility that the spray pumps will
come on simply because one sensor malfunctions(thereby necessitating a time-consuming cleanup of
the building), the logic circuitry for the spray pumpsystem requires that at least two of the three sensors simultaneously record a pressure increase to30 psi or above. Because the sensors are connected to the logic circuit by independent wiring, anelectrical transient in the wiring leading to only oneof the sensors (which might cause the control room
i nstrument to record a spurious spike) would not
activate the spray pumps; only a real increase inbuilding pressure could conceivably have such aneffect.
Strangely enough, others in the control room
area have testified that while they too heard the"thud" described by Flint, they did not even becomeaware of the existence of a spike or the activationof the spray pumps on Wednesday. Gary Miller, theStation Manager, has consistently given statements
and testimony that he heard a "loud deep noise"
while standing in the control room shortly before heleft for the Capitol, but that he does not believe heknew on that day either that there had been a spikein the building pressure instrumentationor that the73-77
spray pumps had activated.
Joe Logan gave
similar testimony. 78
Lee Rogers has also testified that he heard anoise and heard conversation or was told that thenoise was probably caused by ventilation dampers
in the control room ventilation system slamming
shut. 79 ( Miller has also testified that he recalls
hearing someone comment that the noise might be
the ventilation system.) Rogers also denies knowing
either of the pressure spike or the spray pumps
coming on.
George Kunder, who accompanied Miller to Harrisburg, does not recall hearing a noise or knowing
on Wednesday of the pressure spike or the activation of the spray pumps.80
I mmediately after the pressure spike, Joe Chwastyk recalls "a lot of conversation with just about

everybody in the control room" about whether "anybody knew what was happening, because I didn't at
the time." 81 Nor did Mehler immediately recognize
what happened. But Mehler recalls that shortly
thereafter, perhaps 10 minutes to an hour later, he
and Chwastyk talked the matter over and realizedthat there might have been an explosion. 82.83
Chwastyk does not specifically recall the conversation with Mehler, but acknowledges it is quite possible that such a conversation occurred. 84 According
to Chwastyk's recollection, some time after the
event he began to ponder its significance and "it just
flashed through [his] mind" that one of the control
room foremen, Fred Scheimann, had manipulated avalve at precisely the same time that the pressure
spike occurred. What Chwastyk realized was that if
the valve position had been changed by the operation of a DC (direct current) motor in the containment building, the motor might have created a sparkthat could have detonated any flammable gas
present. "And I think it was after someone related
to me also the noise they had heard that I assumed
then it was some sort of hydrogen explosion." 85
Chwastyk himself "assumed it was hydrogen"that must have caused any explosion in the reactor
building, admitting in testimony before us that he8
knew of nothing else that might have exploded. s
Mehler has testified that he does not recall the possibility of hydrogen having come up in his conversation with Chwastyk that afternoon. He remembers
thinking onlythat it might have been a "chemical
82,87
reaction."
As Mehler recalls, he does not beli eve he considered hydrogen to have been thecause because he "didn't think hydrogen could form
that quick in the building to that concentration inthat period of time." 83 Mehler testified that the possibility of hydrogen never entered his mind until he88read it in the news media.
There is no question that after thinking the matter
over, both men became quite concerned. Mehler
recalls being "really a little scared." 89 As Chwastyk
90
puts it, "It scared the hell out of me ..."
Therefore, at least two supervisors in the control
room realized sometime shortly after the event that
there had been an actual pressure excursion in thereactor building and that it had probably beencaused by an explosion, and both were alarmed bytheir conclusions. Chwastyk agreed in testimony
before us that his conclusion certainly "changed[his] view of how serious the situation had been up
to then."85 Whether their conclusions were communicated to anyone else in the control room on
Wednesday, in particular to their superiors, is muchless clear.
Mehler recalls that "we did inform the people inthe [shift supervisor's] office that we did have the
90 4pressure spike, and just about everyone in the control room knew it." 91 He has testified that he believed both Ross and Miller were "in there," and that
it is his recollection that both were informed that the
spike indicated an actual pressure increase. 92 However, Mehler does not recall a discussion with anyone other than Chwastyk about the possibility of a"chemical reaction," although according to Mehler,
he and Chwastyk did not discuss
whether they91
should keep that possibility quiet.
Chwastyk, who apparently considered the possibili ty of a hydrogen explosion more concretely than
Mehler, testified that he could not be certain he related this possibility to Miller, but his best recollection was that he had done so, even though he does
not specifically recall that hydrogen was mentioned. 92 Chwastyk definitely recalls that upon realizing that an explosion may have occurred, hesought Miller's permission to begin
to try to redraw
85,93
the "bubble in the pressurizer."I n an unsworn
but transcribed interview with Chwastyk on October
11, 1979, he related at one point that during this request he had explained to Miller what he thought
93
Later in the inhad happened with an explosion.
terview, Chwastyk said that he was "pretty sure" hetold Miller about the explosion, but he was not sure
he could swear to it:

ably" discussed it with Mehler, and felt "sure" hehad discussed it with other individuals, but could notrecall specifically anyone else with whom he might
have discussed it, other than an inspector from the
NRC. 97
I n spite of Chwastyk's testimony, neither our investigation nor any of the other investigatory groups
to whose depositions and interview memoranda wehave had partial or complete access98 has beenable to identify any Met Ed or B&W personnel who,
on March 28, were told of or made the connection
themselves between the pressure spike and theclosing of a valve, or who considered it a possibility
that the pressure spike represented an actual explosion. As pointed out, neither Miller, Kunder, Logan, nor Rogers has admitted that they even knewthat there had been a pressure spike. Ross, Flint,
and Zewe all remember knowing of the spike andthe activation of the spray pumps, but did not conclude that the spike reflected an actual pressure
surge nor did they conceive that an explosion could
have occurred. Furthermore, an entry in the control
room operator log book for the afternoon of March
28 notes that at 1:50 p.m. an engineered safeguards
i nitiation signal was received, the reactor building
sprays came on, and the reactor building pressure
spiked up to 4 psi.
With respect to the question of Miller's
knowledge, both Chwastyk and Mehler, as noted,
believe that Miller was informed of the pressure
spike, but Miller insists he did not learn of it until Friday. Ross, in a deposition conducted by the SIG on
September 18, 1979, testified that both he and Miller
were in the control room when the spray pump actuation and pressure spike were reported and that:That's what I thought. Most definitely I did thinkthat [an explosion had probably occurred]. Now,
whether or not I related that to Gary then, now that
I think about it, I don't really remember. I may havejust gone back to Gary and asked permission again
to redraw the bubble. I just can't remember if I related to him my thoughts at the time of the correlation of pressure spike in the operation of thevalve.

We, being Miller, I and the group, looked back andsaid, guess we just felt that it was either one:something we just didn't understand, and we didn't
associate
it with anything else and we just went99
on.

I n a sworn deposition on October 30, when pressedon the issue, Chwastyk testified the following:
My best recollection of that is that I did relate toGary that we had some sort of an explosion.
Whether I said it was hydrogen or not, I'm not sure.
But I remember distinctly putting together theoperation of the valve and the95
spike, and I think I
related those thoughts to Gary.

Ross seemed to think this had occurred after Miller
returned from Harrisburg (which would have been
after 4:30 p.m., several hours later). As he recalled,
Zewe reported the spike to him, and "we came tothe conclusion, be it right or wrong, that it was anelectrical spike of some kind and not a pressure
spike in the building."
Pressed in a later deposition taken on October
30, Ross said that his recollection about having any
conversation with Miller on this subject was "a little
vague," but he did remember being in the control
room with Miller looking at some other instruments,
the operators reporting that the building spray had
come on, and Miller saying the following:

A few minutes later in the deposition, however,when it was pointed out to him that Miller's best
recollection was that he had not learned of such an
explosion until Friday morning, Chwastyk testified,"that could very well be true. Again, I can't
absolutely-if Gary said-I may not have told him
what I thought
at the time, because I really wasn't
96
certain."
Asked whether he recalled talking with anyone in
the control room on Wednesday, in addition to Miller, about his fear that a hydrogen explosion might
have taken place, Chwastyk testified that he "prob-

Did you hear that, or did you feel that? Something
to that effect. I'm not sure what that was. And we

90 5

just kind of went right by it. We looked at it and we
told Gary, it's not time to get nervous now. We'regoing to have to go from where we are. And that's
what we did loo

According to Miller's recollection, he first learned
that there had been a "hydrogen burn" from Met Ed
consultant, Bill Lowe, when Miller came into work on
Friday morning, March 30. He recalls that Lowespoke to him about the pressure spike and diagnosis of it, and that Ivan Porter, the lead Instrumentation Control Engineer for Unit 2, showed
him a59,103graph of the spike on that same morning.
Porter, who tends to corroborate Miller's account,
testified in a deposition conducted by the SIG thathe probably first learned of the pressure spike on
the morning of the 30th, and that Gary Miller asked
him to look at the charts and see if Porter thought
they showed a "real valid indication versus, say, amalfunction of that pressure recorder the instrument
104
supplied or whatever."
Porter undertook this assignment by looking at the strip charts for reactor
coolant system pressure, which is measured relative
to reactor containment building pressure. Observi ng that the graph for coolant system pressure decreased slightly for a short time at 1:50 p.m. (indicating a rise in building or reference level pressure),
Porter concluded that the pressure spike had beena reliable indicator of building pressure, and communicated this information to Miller. Porter stated
the following:Ross further explained that his reference to getting"nervous" was that he thought perhaps Miller was"hearing things" or "imagining things." Ross did notrecall if Miller actually looked at the pressure spikeon the chart, and he does not recall any further discussion of the matter with Miller later in the afternoon when Miller returned from Harrisburg. 100
I n previous statements and testimony, Miller has
been quite consistent in his account of when he firstlearned of the pressure spike and the diagnosis of a
possible hydrogen explosion. ? 76 Confronted withthe testimony of Chwastyk, Mehler, and Ross in adeposition on October 29, Miller continued to maintain that he did not learn of the pressure spike on
March 28. Nor, he said, did he recall either a request from Chwastyk that afternoon to try to redraw
a bubble in the pressurizer, or approving
such a101
step in a conversation with Chwastyk.
Furthermore, Miller has pointed out to us in thecourse of the investigation that he had absolutely noreason to conceal or cause anyone else to conceal
this information had he known it on Wednesday.
And he testified under oath that at no time did hewithhold significant information of any kind or instruct anyone else in the control room to withholdsuch information from the NRC inspectors
in the102
control room or from the NRC itself.
Miller's April 1979 written statement, prepared forpresentation to various congressional subcommittees and NRC's IE investigators, arose out of a joint
effort to reconstruct the events of the first day of
the accident by a number of individuals who were in
the Unit 2 control room on March 28. After the accident, these individuals collegially attempted tocreate a reliable chronology of events. Miller has
pointed out that those discussions were taped andthat the tape would provide a more reliable indication of what various individuals knew or did notknow the first day of the accident than their recoll ections today. He had also pointed out that during
those conversations none of the individuals present
recalled learning of a hydrogen burn or explosion
the first day. We have reviewed a tape recording
provided to us by Met Ed of this conversation, and it
i s consistent with Miller's testimony. The tape (side1, about 10 minutes in) indicates that Miller recalled
hearing a noise and turning to another individual to
ask what it was. The tape suggests that Miller may
have heard about the spray system going on atabout 5:00 p.m., when he returned from the Capitol,
but does not make clear whether that information
was linked with the pressure spike.

My impression was, I think he had just learned of it,
and wanted me to look at the charts and stuff involved and tell him what I saw. I don't know, but I
felt it was like somebody just told him, you guys
had a hydrogen explosion, and he wanted me totake a look at the charts and stuff and tell him what
I could find out from them. 1°4

In this connection it may be significant that both
Chwastyk and Mehler recall that they did not reallyfigure out that the pressure spike might have beencaused by an explosion until sometime after the
event. Miller recalls that it was perhaps 30 minutes
after he heard the noise that afternoon that hedeparted for Harrisburg. But State logs show that
Miller, Kunder, and Herbein arrived at the Lieutenant
Governor's office at 2:30 p.m., and Herbein's own
records show his departure from the Observation
Center across the river from Three Mile Island at
1:55 p.m. It is probably very close to a 1h-hour trip
from the plant and into Harrisburg, so Miller musthave been virtually on his way out of the control
room at the time the pressure spike occurred.
The timing of Chwastyk's request to Miller to"redraw the bubble" in the pressurizer is therefore
rather puzzling. According to Chwastyk he spoke
to Miller after he had connected in his own mind thepressure spike and the valve operation. However,this conversation would probably have been after
Miller left the control room. Such a conversation
could have been held after Miller returned at 4:30 to
90 6

Why the change in recollection? Mehler testified
that between October 11 and 30, he had talked withothers who had been in the control room on March
28 (Miller, Ross, Zewe, and Chwastyk), and thatnone of them recalled the instructions having been
given that day. Some, however, had told him they
remembered such an instruction being given after
March 28. Therefore, Mehler concluded that hemust have been mistaken. Mehler acknowledgedthat his "own recollection, faulty or not, standing
alone, has been that it was the 28th," but statedthat it "seems funny, if I would be the only one that
remembered it happening on the 28th when there
were people in the room that don't remember it." 110
Chwastyk also recalled the instruction not tostart electrical equipment in the reactor building because of the spark potential, and that someone hadjust started the oil lift pumps. Chwastyk testified
that he did not believe this could have happened on
March 28, because he recalled the instruction havi ng been given while he was physically present in
the shift supervisor's office and he did not111recall
having been in that office at all on March 28.
No other witnesses recalled such an instruction
having been given on Wednesday, March 28. Control room operator Theodore lilies stated in an NRC
investigation report that the hydrogen explosion was
discussed in the control room on the 28th. The
NRC found that lilies was apparently mistaken
and80
Our rethat the discussion occurred on the 29th.
view of the evidence indicated that the NRC
investigator's conclusion was correct. Additionally,
William Lowe of Pickard, Garrick & Lowe, consultants to Met Ed, recalled in a SIG interview that therecorder trace showing the pressure spike wasbrought to him after 9:00 p.m. on March 29, andthat59he then notified Met Ed, GPU, and B&W personnel.
The only contemporaneous documents that mightshed light on when such an instruction was given
are the control room log book and a set of notes
taken throughout the first few days of the accident
by two Met Ed employees, Don Barry and Walter"Bubba" Marshall, neither of whom is a licensed
reactor operator. The notes, which are extremely
sketchy for March 28, do not record such an instruction on any day. The control room log bookcontains an entry at 9:14 p.m. on Thursday the 29th:"Placed RCP lift pumps in off (minimize sparking potential in reactor building)."Thus, an instruction not to start electrical equipment in the reactor building on account of anawareness of a potential hydrogen explosion apparently was issued shortly after 9:00 p.m. on
Thursday. The log entry does not, however, necessarily reflect an awareness of the earlier explosion

5:00 p.m., but charts of various system parameters,
i ncluding pressurizer level, suggest that Chwastyk
may have begun to try to redraw a bubble beginningaround 2:00 p.m. that afternoon; his account of his
attempt to manipulate pressurizer level fits with theobserved parameters in a number of respects. On
the other hand, Ross (Chwastyk's superior after
Miller left the control room, from 2:00 until 4:30
p.m.) testified that he recalls no attempt during this105
entire time to redraw a bubble in the pressurizer.
Did anyone, then, other than Chwastyk, clearly
realize on March 28 that a hydrogen explosion may
have occurred? At one point in our investigation it
appeared that some light might be shed on thisquestion by testimony that an order had been given
on Wednesday not to start any electric equipment in
the reactor building for fear of the consequences ofa spark. In an unsworn but transcribed interview on
October 11, Mehler recalled that although he had notconnected the pressure spike and simultaneous
operation of a valve at 1:50 p.m., somebody else obviously had. Later that afternoon he was told not tostart oil lift pumps that must be run before the main
reactor coolant pump can be started: "not to do
anything that could give an ignition." 83 Mehler recalled responding to Miller that he had already tested these pumps and they were ready to go. 106
In a sworn deposition with Mehler several weeks
ater,
he recalled that the instruction was "given inloff-;enot to start anything
the shift supervisor's
were
other
people in the room.
electrical ... there
They would have been aware of the instructions. I
believe the instruction came from Gary Miller."
Mehler recalls telling Miller that he had alreadystarted the pumps, and recalls the comment being
made, "Well, then I don't think we have anything left
i n the building." Mehler thinks it was somebody
else,
107
not himself, who made that comment.
At the October 11 interview, Mehler was quite
certain that the instruction not to start electricalequipment had been issued on March 28, prior to
the attempt to restart one of the main reactor
coolant pumps Wednesday evening:

I can say for a fact and will go under oath and I willtake a lie detector test, prior to running the reactor
core (sic) pump, someone did tell us not to start
anything and I remember tellingm
Gary, it's too latenow, I have already started them.

However, by the time of the October 30 sworn
deposition, he had become quite unsure of his
recollection as to which day he received the orders. 109 In the deposition, Mehler testified that hebelieved the orders probably occurred either on
Thursday, March 29, when he was also in the control room from about 1:00
p.m. until about 11:00 p.m.,110
or on Friday, March 30.

90 7

on Wednesday afternoon. Fear of the possibility ofsignificant hydrogen in the reactor building due tofuel cladding failure could have given rise to such anorder by Thursday night, even without knowledge orappreciation of the earlier pressure spike, becauseby that time the existence of a possible hydrogen"bubble" was beginning to be postulated.

themselves and realized that there might have been
an explosion. Thus, if Chwastyk related his conclusions to Miller, this would have occurred after Miller
returned at about 4:30 or 5:00 p.m., at the time
when Miller was instructed by Herbein to repressuri ze the system. However, such a supposition is inconsistent with Chwastyk's testimony that he recalls
getting permission from Miller to redraw a bubble in
the pressurizer, and with the charts showing thatsuch efforts may have been made around 2:00 p.m.
Neither Miller nor Ross, however, recalls any attempts being made to redraw a bubble during theafternoon.
Except for Chwastyk's testimony, no other evidence indicates that anyone in the control room
realized on March 28 that there might have been ahydrogen explosion in the reactor building, or that
Miller was aware of such a possibility. No evidence
suggests that Met Ed management officials in the
Observation Center or GPUSC officials in New Jersey were informed either about the pressure spikeor about the possibility of any explosion. No evidence, either documents or testimony, establishes
that NRC employees either at Region I Headquarters in King of Prussia, Pa., or in Washington were
aware on Wednesday of the pressure spike or of
the possibility that large amounts of hydrogen had
probably been generated during the first 10 hours of
the accident.
At the time the pressure spike occurred, at least
two of the five NRC inspectors that had arrived atabout 10:30 a.m., were in the area of the Unit 2 control room. They were James Higgins, a Reactor
Operations Inspector, and Don Neely, a Health Physics expert. Two other inspectors who had comeonto Three Mile Island, Charles Gallina and Ronald
Nimitz, had gone to the Unit 1 control room. The
fifth inspector, Karl Plumlee, was performing radiation surveys outside of the plant buildings. A
second team, composed of an inspector and an investigator from Region I, Walter Baunack and Raymond Smith, arrived at TMI around noon, but did not
get to the Unit 2 control room until approximately
3:00 p.m. or later. 113.114
In sworn depositions, neither Higgins nor Neely
recalled having been made aware of the pressure
spikex5,16 Higgins kept a spiral notebook of information to pass back to Region I, which had a direct
open line to the Unit 2 control room during most of
the afternoon, but his notes neither reflect the pressure spike or a possible pressure excursion in thereactor building, nor the actuation of the spraypump system. Nor have we discovered anyone at
Region I or NRC Headquarters who recalls being
made aware of the spike or the possibility that an
explosion might have occurred.

Mehler recalls that it was Miller who gave theorder; however, Miller's best recollection is that hewas not in the control room at 9:15 p.m. on Thurs112
day evening when the instruction was given.
In
any event, Miller does not recall having given suchan instruction at any time.

Mehler's recollection that the instruction not tostart electrical equipment was given on March 28,
was keyed to his recollection that it came just after
he had started oil lift pumps for a reactor coolant
pump. Mehler originally believed that this happened
Wednesday because at that time the reactor
coolant pumps were all off, and efforts were being
made to restart at least one pump. No pumps wererestarted on Thursday. However, preparations wereapparently made Thursday or Friday to restart oneof the nonoperating pumps in case the operating
pump should for some reason trip off, and these
preparations would .require testing the oil lift pumps.
To summarize, only one person present in thecontrol room on March 28-Chwastyk, the shift supervisor in charge of the consoles-has acknowledged that he realized the pressure surge wasreal, evaluated that in connection with a valve
operation, and concluded that a hydrogen explosion
had probably occurred in the reactor containmentbuilding. Others present either say they did notknow of the pressure spike, or dismissed it as anelectrical transient, except for Mehler, who fearedthat a chemical reaction had taken place but did not
believe it was a hydrogen explosion (and therefore
did not necessarily have a reason to believe that
substantial core uncovering had occurred). Several
say they heard a noise but believed it to have been
the control room ventilation dampers cycling.
Chwastyk believes he related his conclusion toMiller, but is not certain that he did. Miller does notrecall being aware of the pressure spike or thespray pumps coming on. Others testified that Miller
probably was informed of these events. It may besignificant that Kunder, who accompanied Miller toHarrisburg shortly thereafter, and a number of others in the control room have also testified that they
were not aware of the spike.
According to documents tending to establish thetime Miller and Kunder left for Harrisburg, Miller evidently departed the control room before Mehler andChwastyk discussed the pressure spike among908

However, quite a number of others in the control
room recall that an inspector was standing in thecontrol room and was in a position to observe thepressure spike directly and the ensuing response to
it by control room operators and supervisors. For
example, Zewe recalled that an NRC inspector was
standing directly behind him when the spike occurred. 117
The most specific testimony relating to this question was given by Mehler. Mehler recalls that when
he came out of the shift supervisor's office, an NRC
i nspector followed him out of the office and "wasbehind us" when Mehler instructed the spray pumps
118
turned off.
The inspector, according to Mehler,
asked why he had given such an instruction, andMehler explained to him that there had been a pressure spike but that the pressure had gone down,
and that Mehler did not know what had caused thepressure increase. Mehler specifically recalls explaining to the inspector the coincident two-of-threelogic of the spray pump system. According toMehler's testimony, the inspector did not seem tounderstand what had happened, and did not make119
any further inquiry about it.
Mehler could not identify the inspector, but testified that the individual was not Neely, whom heknows from the TMI postaccident recovery effort.
He described the inspector as being medium height,
with dark hair and a little gray around the sideburns,
aged perhaps 30. 120 Mehler's description does not
fit James Higgins, who is a tall (well over 6 feet), thin
man in his midthirties. According to Mehler, he recalls that the individual he talked to was wearing awhite hard-hat with "U.S. NRC" emblazoned on it,
also suggesting that perhaps the inspector had only
recently entered the control room from elsewhere in
the plant. (Mehler testified that the only NRC inspector in the control room on the 28th whom herecognized was 121
Donald Haverkamp, the Project Inspector for TMI.
Haverkamp was, in fact, in Kingof Prussia, Pa., on Wednesday and did not arrive at
TMI until Thursday, March 29.)
Chwastyk also recalls that "there was an NRC
i nspector ... standing behind Mehler when we shut
122
down the spray pumps."
Chwastyk's recollection
i s that the individual was about Mehler's height( Mehler is about 5 feet, 8 inches tall), but somewhat
heavier. Chwastyk did not know the names of anyof the NRC personnel in the control room March 28,
and does not think he could identify the individual hesaw standing behind Mehler if he saw him today.
Nor does he recall whether Mehler had a conversation with the inspector.
More important, Chwastyk testified that he had"some recollection of talking to someone from the
NRC" about his conclusion that there might have
909

123

been an explosion in the reactor building.
Chwastyk does not recall whether it was the sameinspector he observed standing behind Mehler when
the spray pumps were turned off, but he does recall
the following:
Relating to someone from the NRC that I think we
may have had an explosion in the building, but I
wasn't sure. And that was about it, and I was probably a little curt because I had other things to do. 124

Neither Higgins nor Neely recalls any such
conversation, nor do Higgins' notes record such information. It appears that the only other possibility
i s that Ronald Nimitz, who was stationed in the Unit I
control room, may have been in the Unit 2 control
room at this time and may have talked to Chwastyk
and Mehler about the' pressure spike. Nimitz was
definitely in and out of the Unit 2 control room duri ng the afternoon, according to his recollection. He
does not recall learning about either the pressure
spike or the possibility of an explosion, nor do hisnotes reflect such information. Nimitz is not a reactor operations inspector, but he has had nuclear engineering and reactor operators training, and he testified in a deposition taken by the SIG that had hebeen informed of the spray pumps actuating, such
i nformation would have been 125very significant to him
and he would have recalled it.
When Chwastyk was pressed as to whether hetold anyone else about his conclusion that there
might have been an explosion in the reactor buildi ng, and as to why that fact did not seem to havebeen common knowledge until late Thursday or Friday morning, Chwastyk responded that he thought
he had reported to Miller and the NRC inspector,
and that he "must have talked to other people in thecontrol room," including his counterparts who relieved him late that night. But he could not recall
anyone specifically with whom he had talked. He
did not recall discussing the matter 126
with Kunder,
and was not sure about Mike Ross.
Chwastyk
denied that he, or he and Mehler, made any decision
to hide the possibility that an explosion had occurred, but admitted that they "didn't just make it
general knowledge to everybody in the control
90
room."
As for the NRC inspector, Chwastyk conceded that "maybe I should have explained more [tohim] but I just didn't127
have the time. At least I didn't
feel I had the time."
He recalled that his primaryconcern was dealing with the reactor coolant system.
What conclusions can be drawn, then, from thisevidence as to whether Met Ed personnel willfully
withheld significant information from the NRC? No
evidence indicated that company management off
the island was aware of the pressure spike or thepossibility that an explosion had occurred on
Wednesday, March 28. The top official on site, Gary
Miller, the Station Manager, has consistently testified that he did not become aware of the spike or
the possibility that an explosion had occurred until
Friday morning. Testimony from more than one witness indicates that Miller was aware of the pressure
surge on Wednesday, but this testimony is less thanclearcut; some other testimony tends to corroborate
Miller's account.
Even if Miller knew of the pressure spike, possibly he dismissed it or failed to recognize its significance, because other supervisory employees who
were in the control room and their coworkers did
not believe that the spike actually reflected a pressure increase. Such an interpretation of the spike
appears to have been technically deficient: at least
two supervisors recognized that the actuation of thespray pumps probably compelled the conclusionthat there had actually been a pressure excursion in
the building. On the other hand, in the minds ofmost or all of those present in the control room,
serious consideration of the possibility that a hydrogen explosion had occurred probably would havecontradicted all the assumptions under which they
were proceeding to try to cope with the accident.
Only Chwastyk's testimony made Miller awarethat an explosion might actually have occurred.
Such testimony might give rise to an inference that
Miller withheld such information from the NRC, except that Chwastyk is not certain that he did indeed
tell Miller, and Chwastyk also testified that he himself informed an NRC inspector present of this possibility. Chwastyk also testified that he explained
the pressure spike and its significance to the sameor another NRC inspector right after the event.
There is no dispute that at least two NRC inspectors were on hand in the control room observing
plant operations, and that no effort was being madeto restrict their freedom to move about and ask anyquestions they wished to ask. The virtually unanimous testimony of Met Ed witnesses is that an NRC
i nspector was standing directly behind the console
when the pressure spike occurred and the spraypumps went on, and was in a position not only toobserve these events but also to hear the discussion among operators and supervisors about what
had happened. However, none of the three NRC inspectors who may have known or been told about
the spike and possibly about its consequences
around midafternoon on the 28th presently recalls
having been so informed. Chwastyk's recollection,on the other hand, is that the inspector to whom hespoke did not really seem to have understood what

was happening. In any event, none of the inspectors reported the event to Region 1 or to Headquarters in Bethesda.
Of course, if Chwastyk had really told an NRC inspector that a hydrogen explosion might have justoccurred, and explained what that meant to him, it ishard to believe any inspector, or anyone else, would
have taken such information lightly. Chwastyk was,in a de facto if not official sense, the shift supervisor
in charge of the control room consoles. It could beargued that his failure to inform and alert responsible NRC officials of his conclusions and their implications represented a willful withholding of information from the NRC, that merely informing an inspector in the control room should not have beenenough. However, it might also be argued that control room personnel can hardly be expected to double as NRC employees in the middle of an emergency, and that as long as NRC inspectors are present
observing everything that happens, there can seldom be a "conscious withholding" of information"from the NRC."
Perhaps most important, it does not appear to us
that the legal requirements placed on reactor licensees to report significant safety-related information
to the NRC were ever intended as a tool to compel
effective flow of information to the NRC in the midstof an accident or disaster situation. If control roomsupervisors had consciously decided not to tell NRC
i nspectors on site a significant piece of information
because they were afraid of the consequences ofdoing so, the legal requirements might well have applicability in this situation. We did not find evidencei ndicating that that occurred here. Moreover, it isunclear what motive Met Ed personnel would have
had to hide such information from the NRC, whencontrol room personnel were at the same time encouraging the NRC representatives present to provide any ideas that occurred to them to help copewith the unstable reactor.
Summary and Conclusion

The pressure spike was only one of a number ofimportant indicators that were ignored, misinterpreted, or disbelieved on March 28 by control room
personnel. Each of these pieces of information, if
believed and understood, could have given a crucial
clue to what was happening (or what had happened)
during the accident. When viewed together, in hindsight, they should have afforded compelling evidence of core uncovery.
We failed to adduce evidence showing that anyof this information was willfully concealed to hide

91 0

the seriousness of the accident. Yet the pattern offailure to communicate critical information is clear.
A number of factors other than deliberate attempts
to downgrade the seriousness of the situation could
account for this failure. These factors include thei nability to recognize and comprehend the full significance of the information, and certain psychologicalfactors: the difficulty of accepting a completely
unexpected situation, the fear of believing that thesituation is as bad as the instruments suggest, anda strong desire to focus on getting the reactor
stable again rather than dwelling on how bad theaccident is, if indeed the situation is dire.
The failure to recognize and act on significant
data, in our view, demonstrates a lack of technicalcompetency by site employees to diagnose andcope with this accident. But neither lack of such acapability nor the psychological factors mentioned
above amount, in our view, to an intentional withholding of information. Moreover, NRC and B&W
employees in the control room also did not recognize or communicate critical information. Theiroffsite organizations did no better, and perhaps
worse, than the utility's offsite engineers at GPU in
New Jersey in demanding reporting of important information and in recognizing the significance of that
i nformation which they did receive. The fact that
NRC and B&W did no better than Met Ed or GPU inreporting critical information up the management
chain and acting upon it, tends to support our conclusion that there is no evidence to show willful
withholding of information by Met Ed from the NRC.
e. Findings and Recommendations
Findings• The evidence fails to establish that Met Ed

management or other personnel willfully withheld
i nformation from the NRC.
• I nformation conveyed by Met Ed, B&W, and NRC
personnel from the control rooms to their
managements and offsite organizations was inmany cases incomplete and delayed. On several
occasions, interpretations of plant status thatwere incorrect were provided by personnel in thecontrol room when the mere provision of instrument readings would likely have been more definitive and could have led to an earlier realization of
the true plant status.

• NRC personnel both in the control room and offsite were unfamiliar with plant systems and some91 1

did not have a basic understanding of plant
operations, both of which interfered with the flowof information.
• Communications from NRC offsite emergency
response centers to the control room were undisciplined in that several personnel were allowed
to request information, no priority was established to identify the more important information
requests, no followup was provided to ensurethat the requested information was obtained or atleast acknowledged as not available, and various
inquiries about reactor status were uncoordinated and not focused to the NRC communicator in
the Unit 2 control room.
• NRC personnel in the Unit 2 control room were
too few to permit independent gathering ofoperations data, to respond to information requests, and to provide continuity in the flow of information.
• Some information was not obtained by the NRC
because of the delay in establishing contact
between Met Ed and the NRC regional office.
Recommendations• The NRC should identify and qualify those NRC

personnel relied upon to obtain or evaluate critical information during nuclear powerplant or radiological emergencies. The qualification should
ensure that the personnel can recognize, diagnose, and properly evaluate abnormal conditions
within their identified area of responsibility.
• The NRC should provide training, equipment, andguidance which ensure rapid, efficient, andcomprehensive gathering of information by NRC
personnel during nuclear powerplant or radiological emergencies. Training and guidance should
ensure that predetermined basic information is
obtained at the scene of the accident, and theequipment provided should be sufficient to ensure immediate and direct communication withthe appropriate NRC emergency response
centers.
• The NRC should determine the minimum staffing
and composition of the initial NRC response
teams, both on site and off site, for nuclear
powerplant accidents and other foreseeable radiological emergencies. For purposes of obtaini ng plant operations information during nuclear
powerplant accidents, no less than three personnel qualified in reactor operations should be assigned to the control room to obtain and communicate plant status information.

REFERENCES AND NOTES'Chart, TMI-2, Recorder HP-UR-1901, March 28,1979.
2
Offsite Dose Calculation Sheet, TMI-2, March 28,
1979, 0744.
3
Crawford Interview on May 22,1979 (IE) at 3.
4
Benson/Crawford Interview on May 3,1979 (IE) at 8.
5
Dubiel Interview on May 22,1979 (IE) at 3.
6
Miller Interview on April 12, 1979 (Met Ed) at 14.
7
Offsite Dose Calculation Log, TMI-2, March 28,1979.
B
Reilly Interview on May 3,1979 (IE) at 53-54.
9
Region 1 Incident Response Center Transcripts,
March 28, 1979.
10
Arnold dep. (Sept. 24, 1979) at 5-6.
11
Region 1 Incident Response Center Transcripts,
March 28,1979, Tape 17A at 8-9.
12Porter Interview on May 21, 1979 (IE) at 3-13.
13
Miller dep. (Sept. 20, 1979) at 14-16.
14
Porter dep. (Oct. 30,1979) at 4.
15
Porter Interview on May 21, 1979 (IE) at 9-17.
'6 Id. at 5.
170, at 18.
18
Wright Interview on June 15, 1979 (IE) at 6-7.
19 Porter dep. (Oct. 30,1979) at 5,11-13.
20
Porter Interview on May 21, 1979 (IE) at 19-20.
21 Porter dep. (Oct. 30,1979) at 38.
22
Miller dep. (Oct. 29, 1979) at 3-6.
23
Porter dep. (Oct. 30,1979) at 13.
24 Miller dep. (Oct. 29, 1979) at 8-9.
25
Yaeger Interview on June 20,1979 (IE) at 14.
260. at 16.
270, at 18-19.
28

Wright Interview on June 15, 1979 (IE) at 8,14.
at 14, 19.
30Id. at 13.
31
Bennett Interview on June 19, 1979 (IE) at 18.
32
Wright Interview on June 15,1979 (IE) at 11-12.
33
Bennett Interview on June 19,1979 (IE) at 13,18.
290.

34

Porter dep. (Oct. 30,1979) at 9-11,18, 24.
Id. at 18.
36
Porter Interview on May 21, 1979 (IE) at 20.
37
Porter dep. (Oct. 30,1979) at 7-8.
38
Porter dep. (Oct. 30,1979) at 13, 24.
39Porter Interview on July 2,1979 (IE) at 6.
35

52

53

at 19.

54
Hq. IRC Day 1 Transcripts, Channel 2, Book 2 at325-339.
55
Hitz dep. at 44-45.
56
Stello dep. at 18-19.
57
Hearings Before the Subcommittee on Energy andthe Environment, 96th Cong., 1st Sess. (May 9-15, 1979)
Part 1 at 12-13.
58
Higgins dep. at 102-103.
59
1-owe Interview Memo, December 4,1979
60
NRC, "Investigation into the March 28, 1979 Three
Mile Island Accident by the Office of Inspection and
Enforcement," NUREG-0600 at 1-4-49-51, August 1979.
81
Logan Interview on May 9,1979 (IE) at 35.

62

Logan dep. at 2.
Faust, Frederick, Scheimann, and Zewe dep. at
256-260.
84
Id. at 257-258.
63

B Ross dep. (Oct. 30, 1979) at 8.
5

Ross dep. (Sept. 18, 1979) at 42-44.
Ross dep. (Oct. 30, 1979) at 8-9.
68
FIint dep. (June 30, 1979) at 21-22 (Pres. Com.).
69
FIint Interview on April 20,1979 (Met Ed) at 4.
70
Chwastyk dep. (Oct. 30,1979) at 5-6.
71
Id. at 6.
72
Mehler dep. (Oct. 30,1979) at 7.
73
TMI Station, March 28, 1979 Incident, Statement by
G. P. Miller, Station Manager, signed April 7,1979 at 24.
74
Miller Interview on May 7,1979 (IE) at 70.
75
Miller dep. (May 31,1979) at 57 (Pres. Com.).
76
Miller dep. (Sept. 20, 1979) at 31-32.
77
Miller dep. (Oct. 29,1979) at 19-22.
78
Logan Interview on May 9,1979 (IE) at 31-32.
79
Rogers dep. at 47.
80
Kunder dep. at 75-76.
B'Chwastyk dep. (Oct. 30, 1979) at 5.
88

67

82

Mehler dep. (Oct. 30,1979) at 10.
Mehler dep. (Oct. 11, 1979) at 15.
84
Chwastyk dep. (Oct. 30,1979) at 8,14,17-21.
83850. at 15.
88

40

MiIIer dep. (Oct. 29,1979) at 5-6.
wrightInterview on June 15,1979 (IE) at 24-25.
42
Bennett Interview on June 19,1979 (IE) at 17-18.
43
Porter dep. (Oct. 30,1979) at 14-17.
"Porter Interview on July 2,1979 (11E) at 12.
45Wright Interview on June 15, 1979 (IE) at 9.
46
Yaeger Interview on June 20,1979 (IE) at 9-11,14.
41

47

Hq. IRC Day 1 Transcripts, Channel 2, Book 1, at 188.
Region 1 IRC Transcripts, March 28, 1979, Tape 10

87

0. at 14.
Mehler dep. (Oct. 11, 1979) at 14.

m

Id. at 11.

88

Mehler dep. (Oct. 30, 1979) at 22-23.

80

Chwastyk dep. (Oct. 30,1979) at 20.

Mehler dep. (Oct. 30,1979) at 17.
0. at 17-18.
93
Chwastyk dep. (Oct. 11, 1979) at 18.
91

92

Porter dep. (Oct. 30,1979) at 5-6.

94

48Porter Interview on July 2, 1979 (IE) at 6-7.

95

49

Porter dep. (Oct. 30,1979) at 6-7.
Miller dep. (Oct. 29,1979) at 10-11.
51
Herbein dep. at 16-17.
50

98

97

91 2

0. at 21-22.

Chwastyk dep. (Oct. 30, 1979) at 17.

0. at 19-20.
/d. at 17-21.

These include all of the transcripts of taped interviews conducted by NRC's Inspection and Enforcement
Office; all of the President's Commission depositions withMet Ed, B&W, and NRC personnel; and some additional
records of interviews including some transcripts of taped
interviews of Met Ed personnel by congressional committee investigators, provided to us by the witnesses themselves.
Ross dep. (Sept. 18, 1979) at 42.
100
Ross dep. (Oct. 30, 1979) at 10.
101
Miller dep. (Oct. 29,1979) at 24-28.
102
Id. at 30-32.

identify them in order to determine whether Mehler had
made statements earlier than the October 11 interview
regarding the date of an instruction not to start electricalequipment. However, the SIG has not discovered any
earlier interview in which Mehler was asked about thissubject, nor did Mehler recall ever having discussed it
with110any investigator before October 11.
Mehler dep. (Oct. 30,1979) at 15-16.
111
Chwastyk dep. at 15-17.
112
Miller dep. (Oct. 29, 1979) at 23-24.
Smith dep. (Nov. 19,1979).
114
Baunack dep. at 7-8.
15t Neely dep. at
16-17.
'*Higgins dep. at 5-6.
117
Faust, Frederick, Scheimann, and Zewe dep. at 259.
11
eMehler dep. (Oct. 30,1979) at 8.
f19
Id. at 8-10.
120k1. at 10, 21.
121Id. at 19.
122
Chwastyk dep. (Oct. 30, 1979) at 18.
123
14. at 21.
124
14. at 22-23.
125
Nimitz dep. at 21-23.

98

103
104
105

b. at 19-22.
Porter dep. (Oct. 30,1979) at 27.

106
107
108
109

Ross dep. (Oct. 30, 1979) at 13.

Mehler dep. (Oct. 11, 1979) at 16, 25.

Mehler dep. (Oct. 30,1979) at 11-13.
Mehler dep. (Oct. 11, 1979) at 25.

1 n the interim, an October 21 front-page story in the

New York Times reported that Mehler had told the Special

Inquiry Group that such an instruction had been given on
March 28. The story also referred to testimony by
Mehler reflected in "notes" taken by a "Federal investigator" in July 1979. Since the notes (a copy of which thestory said had been obtained by the Times) were notthose of the staff of the SIG, an attempt was made to126

Chwastyk dep. (Oct. 30, 1979) at 19.

127 Id. at 23.

91 3

cluding station superintendent, before moving to thecorporate offices. Gary Miller, Station Manager, reported directly to Herbein. Miller graduated fromthe U.S. Merchant Marine Academy and had 8 yearsof nuclear construction and testing experience with
U.S. Navy reactors before joining GPUSC in 1973.
Miller became the superintendent of Unit 2 in 1974
while the plant was under construction and hemoved to the site superintendent (later station
manager) position in 1976. In this position, he wasprimarily
concerned withadministrative andmanagerial duties as opposed to directing the dayto-day operation of the reactors.
Both Dieckamp and Arnold worked at GPU corporate offices in New Jersey. Creitz and Herbein
worked at the Met Ed corporate offices in Reading,Pa., about 50 miles from the TMI site, and Miller
headed the Met Ed staff at the site.
Joseph Logan, Unit Superintendent, reported toMiller and was responsible for the overall operationof Unit 2. Logan graduated from the U.S. Naval
Academy and had 20 years of nuclear power traini ng and operating experience as a commissioned
officer in the U.S. Navy before joining Met Ed in earl y 1978. He became unit superintendent after theplant began commercial operation in late December
1978. James Floyd, Supervisor of Operations, andGeorge Kunder, Superintendent of Technical Support, were assisting Logan. Floyd graduated from
Columbia University with a degree in chemical engineering and had a background of nuclear training
and operations experience as an enlisted man in the
U.S. Navy before joining Met Ed in 1968. Floyd had
3 years of experience as operations supervisor, incharge of operating personnel, at GPU's Saxton
training facility and TMI-1 before his appointment as
operations supervisor at Unit 2 in 1975. Kunder, on
the other hand, graduated from Pennsylvania State
University with a degree in mechanical engineeringand joined Met Ed in 1968 where he received his
nuclear training and operating experience. Kunderprogressed through a variety of staff engineering
assignments before his promotion to operations supervisor at Unit 1 in December 1977. In December
1978, Kunder became the Superintendent of Technical Support at Unit 2. James Seelinger held that
position until he was promoted to Unit Superintendent at Unit 1 in December 1978. Seelinger is a graduate of the U.S. Naval Academy and served as acommissioned officer in the U.S. Navy. He had 6
years of training and experience in the operation ofnaval nuclear powerplants before joining Met Ed in
1974.
Several key Met Ed management personnel held
an NRC senior reactor operator license at TMI at

6. MANAGEMENT OVERVIEW OF THREE MILEI SLAND, UNIT 2 (TMI-2)
a. Organization
The Three Mile Island Generating Station near
Middletown, Pa., has two units that use Babcock &Wilcox designed pressurized water reactors. The
Unit 1 nuclear powerplant went into operation in1974 and Unit 2 was started in 1978. Operation ofthese units is the responsibility of the Metropolitan
Edison Company (Met Ed) which owns 50% of each
unit. Met Ed has corporate offices in Reading, Pa.,and is one of three operating utilities belonging to an
investor-owned holding company. This holding
company, the General Public Utilities Corporation( GPU) with offices in Parsippany, N.J., also owns thePennsylvania Electric Company (Penelec) with offices in Johnstown, Pa.; the Jersey Central Powerand Light Company (JCPL) with offices in Morristown, N.J., and the General Public Utilities Service
Corporation (GPUSC) with offices in Mountain
Lakes, N.J. Penelec and JCPL are operating utilities, and each owns 25% of each TMI unit. GPUSC
i s responsible for providing technical and managerial
assistance to the operating utilities primarily in thearea of fuel management and in the design, construction, and startup of new generating units.
Figure 111-8 shows the corporate and line
management relationships within GPU and Met Ed
for the operation of TMI-2 as they existed on March
28,1979.
Both GPU and GPUSC are headed by Herman
Dieckamp who has been involved in the technicalend of the nuclear industry for most of his 30-year
professional career. He joined the corporation in
1973. Assisting Dieckamp at GPUSC is Robert Arnold, Vice President of Generation. Arnold received
nuclear power training and operating experience as
a commissioned officer in the U.S. Navy before joini ng Met Ed in 1969. He was involved in the startup
and operation of Unit 1 and the construction andstartup of Unit 2. He served as Vice President ofGeneration for Met Ed before advancing to GPUSC.
On March 28, 1979, reporting to Dieckamp was
Walter Creitz, then President of Met Ed. Creitz had
been with the company for 31 years holding avariety of engineering and management positions
before becoming president in 1972. His technicalexperience was primarily in non-nuclear work. Reporting to Creitz was John Herbein, Vice Presidentof Generation for Met Ed. Herbein received nuclear
power training as a commissioned officer in the U.S.
Navy before joining Met Ed in 1967. He progressed
through several management positions at TMI, in91 4

FIGURE 111-8. GPU/Met Ed Organization as of March 28, 1979
91 5

some time in their career. Herbein was licensed for
Unit 1 from February 1974 to February 1975; Miller
held a license for 6 months in 1976 for Unit 1; Logan
held a current license on Unit 2 which he received in
December 1978; Floyd was cross-licensed for Unit
2 and has held a Unit 1 license since March 1974;
Kunder held a current license for Unit 1 which he received in August 1975 and was in the process of
being cross-licensed for Unit 2; Seelinger wascross-licensed for Unit 2 and had held a Unit 1
license since January 1977. (Personnel holding acurrent senior reactor operator license for Unit 1
were cross-licensed by the NRC as senior reactor
operators at Unit 2 upon the request of Met Ed, provided that the candidates had successfully completed Met Ed's training program that stressed thedifferences between the two units.)
The NRC approved the management organizationin February 1978 by issuing the operating license.
Incumbents in key positions met the requirements of
the industry standard ANSI N18.1-1971, "Selection
and Training of Nuclear Power Plant Personnel."( Met Ed is permitted under the NRC license to
replace personnel in key positions without priorapproval or prior notification to the NRC, provided
the replacements meet the requirements of industry
standard N18.1 and any additional requirements
li sted in the technical specifications. Logan andKunder met these requirements.)
The NRC staff involved in assessing the acceptability of utility operating staffs believed that qualifications of personnel in the home office were average,
whereas those of employees in the plant were superior.
Although several corporate officials were experienced in the nuclear field and plant management
met current industry and NRC qualification requirements, key management personnel, Logan andKunder, were inexperienced in Unit 2 operations.
Because they were the first two management officials to arrive in the Unit 2 control room on March
28,1979, and they arrived before any significant fueldamage had occurred, we believe that they could
have played a major role in the diagnosis of the
problem had they been better acquainted with plant
operations.
Management control was set up through use of a
traditional line organization. In addition to the normal advice and counsel exchanged between amanager and his staff, Creitz, Herbein, and Loganwere advised on Unit 2 nuclear safety matters byformal review committees institutionalized by either
corporate policy, NRC license conditions, or both.
Additionally, a quality assurance group reported toHerbein. This group inspected and audited activities
related to nuclear safety at the TMI Station.

b. Operating Experience of Key Management
Personnel
TMI-2 was in commercial operation for only 3months before the reactor accident took place on
March 28, 1979. During 1977 and 1978, the unit underwent extensive preoperational and power testing
directed by GPUSC personnel and performed by
Met Ed site personnel.
During the preoperational and power testing
phases Miller had a dual role as Site Manager andUnit 2 Superintendent. Although GPUSC was incharge of these testing programs, Seelinger, thensuperintendent of technical support at Unit 2, performed the day-to-day testing and operation
management duties normally assigned to the unit
superintendent. Miller apparently spent most of histime in his site manager role and delegated many of
the unit superintendent functions and signature authority to Seelinger. 2 ' 3 Logan, after joining Met Ed
i n early 1978, spent most of the remainder of theyear in training toqualify for an NRC senior reactor
4
operator license.
Although Seelinger had unit superintendent signature authority and had signed plant procedures,
safety reviews, test acceptances, and similar documents in the capacity of unit superintendent, hestated that he was not, nor was he acting as, theUnit 2 Superintendent. 2 Consequently, during these
critical
experienceandl earning
periodspreoperational and power testing phases at Unit
2-the position of unit superintendent was in reality
not staffed. The GPUSC startup and engineering
personnel left the site as the testing and startup
programs were completed and initial operations progressed. Seelinger then moved to a new position at
Unit 1 in December 1978. This left Unit 2 with two of
its three key management positions filled by personnel inexperienced in the plant's operationLogan and Kunder.
Floyd, the most experienced member of Unit 2
management, was away for simulator retraining in
Lynchburg, Va., on the day of the accident. During
testimony after the accident, Logan and Kundereach stated that they lacked experience with theUnit 2 facility, 5- 6
Kunder admitted that this inexperience limited his
ability to respond and diagnose the cause of the abnormal conditions that developed on March 28 as aresult of the accident. Miller also recognized hislack of detailed knowledge and called on Herbein,
Seelinger, and the B&W Site Manager, Leland
Rogers, to assist him on March 28. Miller, Logan,
and Kunder were aware of the abnormal conditions
encountered by the shift supervisor before any significant fuel damage occurred. Thus, they had the
91 6

opportunity to prevent or limit core damage hadthey been able to property diagnose the cause of
the abnormal conditions.
The qualifications and training requirements forplant personnel were established by the NRC in thetechnical specifications included in the Unit 2
li cense. These requirements were in the form of anendorsement of the industry standard ANSI N18.11971, "Selection and Training of Nuclear Power Plant
Personnel." This standard includes the minimum
qualifications for plant managers and supervisors.
However, the standard is not specific as to what experience is required with respect to each type of
nuclear powerplant nor the plant at which the person will be working. The standard requires theplant manager to have a minimum of 10 years of"responsible" powerplant experience, 3 of whichmust be associated with nuclear powerplants and 4of the remaining 7 may be fulfilled by academic
training. Moreover, the plant manager (unit superintendent) has to acquire the training and experience
required by the NRC to hold a senior reactor operator license, but he does not necessarily have to holdone. Met Ed, however, required the unit superintendent to hold a senior reactor operator license. Eachof the aforementioned TMI-2 personnel exceeded
the minimum qualifications required in ANSI 18.1.

Furthermore, in December 1978, Seelinger, who had
performed much of the unit superintendent's work in
1977 and 1978, was promoted to Unit 1 Superintendent when Logan took over Unit 2. Kunder came to
Unit 2 then to replace Seelinger as the Superintendent of Technical Support. Apparently, this staffing
arrangement was made by upper management withno recognition of its weakening effect on the technical and plant knowledge strength of the Unit 2 sitemanagement.
We found no evidence that the safety committees
recognized the weaknesses that were developing in
the Unit 2 management structure. Rather, their attention was primarily focused on licensing andoperating experience matters.
Plant Operations Review Committee

The Plant Operations Review Committee (PORC)
i s a requirement of the NRC license. This committee advises the unit superintendent on all mattersrelated to nuclear safety. The PORC is primarily
responsible for review of procedures that affect nuclear safety, review of proposed tests and experiments that affect nuclear safety, review of proposedchanges of technical specifications, and review of
proposed changes or modifications to unit systems
or equipment that affect nuclear safety. In addition,
it investigates violations of technical specifications,
i ncluding the preparation and forwarding of reports
on evaluation and recommendations to prevent recurrence. PORC also reviews unit operations todetect potential nuclear safety hazards, and performs special reviews, investigations or analyses asrequested by the unit superintendent.
There are no NRC or industry qualifications fori ndividual members of PORC. Both Seelinger andKunder, who were chairmen during 1978 and 1979,
possessed extensive education and experience innuclear technology. The remainder of the PORC
members had technical or engineering backgrounds.
A review of PORC meeting minutes indicated thatthe committee reviewed procedures, temporarychanges, design change reports submitted to the
NRC, and the other matters associated with theirassignment. However, the meeting minutes do notcontain details by which we could judge the extent
to which the topics were discussed. We do knowthat some approved plant procedures were contrary
to the technical specifications. 8
For most of 1978, the position of Unit Superintendent was filled by Miller who also had to carry out
his primary responsibility as Site Superintendent.
The time Miller could devote to PORC was severely
li mited and Seelinger performed most of the activities customarily performed by a unit superintendent.

c. Review Committees
Three review committees were established to advise key Met Ed managers on nuclear safety
matters at Unit 2. These were the Plant Operations
Review Committee (PORC), which advised Logan;
the Generation Review Committee (GRC), which advised Herbein; and the General Office Review Board( GORB), which advised Creitz.
Additionally,
Dieckamp established a program for an annual review of the overall operation and status of each nuclear plant in the GPU system. These reviews wereconducted by senior GPU management, including
Dieckamp, Creitz, Herbein, and others, at the plantsites. Miller was not a member of the GRC or
GORB but often attended GORB meetings.
During the critical testing phases of Unit 2 in 1977
and 1978, Miller had dual responsibilities as Site Superintendent and Unit Superintendent. The evidence suggests that much of Miller's time was devoted to his site superintendent duties. He rarely
participated in PORC activities or the technical duties customarily performed by a unit superintendent.
Likewise, Logan, the incoming Unit Superintendent,
was in training for an NRC license and did not participate in PORC or unit superintendent activities until
he assumed that position in late December 1978.
91 7

Logan, who took over as Unit 2 Superintendent at
the end of December 1978, and Miller rarely attended the PORC meetings. Logan attended some
PORC meetings after he became Unit Superintendent. Seelinger went to Unit 1 in late December
1978 and was, therefore, no longer a member of theUnit 2 PORC.
Generation Review Committee

The Generation Review Committee (GRC), theoffsite safety committee, is a requirement of the
NRC license. This committee advises the Met Ed
Vice President of Generation and provides an independent review and audit of designated activities
in the areas of nuclear unit operations, engineering,
metallurgy, radiological safety, and quality assurance practices related to TMI-2.
The GRC is composed of at least five members,
all appointed in writing by John Herbein. The committee, chaired by George Troffer, Manager of Quality Assurance, consisted generally of no more thannine members.
Again, there are no NRC or industry qualifications
for members of GRC. The technical specifications
describe only a general requirement to be satisfied
by committee members. Troffer, who was chosen
to be the GRC Chairman by Herbein, had 32 yearsof experience in the U.S. Navy. He served actively
for over 12 years in various duties in the Navy Nuclear Program. Additionally, he had various assignments in engineering, repair, and quality assurance
while serving as a commissioned officer. The
members of the GRC had previous experience indesign, some had experience in operating naval
reactors, and all had engineering degrees. Three ofthe group worked directly under Troffer in his quality assurance organization.
One of the main responsibilities of the GRC was
to overview the PORC activities. Whereas the position of Unit 2 superintendent for most of 1978 was
filled by Miller, who also had the dual responsibilityof station superintendent and, thus, had only a limited time to devote to PORC matters, this responsibility of GRC was a vital one. However, we found noevidence that the GRC was aware of or concerned
about Miller's lack of presence and participation in
PORC activities. We sampled the PORC activities
carried out during June 5 to September 9, 1978 andfound that of the 47 PORC sessions we reviewed,
Miller attended 2 sessions and Logan, the incoming
Unit Superintendent, attended none.
GRC was required to meet at least once percalendar quarter, according to technical specifications, but it met more frequently. Minutes of these91 8

meetings contain few details. There is no indicationi n the minutes that Herbein attended these meeti ngs.
General Office Review Board

The General Office Review Board (GORB) wasconcerned with broader issues (rather than details)of nuclear safety. The responsibility of GORB wasto (1) foresee potentially significant nuclear and radiation safety problems and to recommend to the
President of Met Ed how they could be avoided, and(2) periodically review the Generation Division audit
program to ensure that audits are being accomplished in accordance with requirements of technical specifications and ANSI 18.7-1976, "Standard for
Administrative Controls and Quality Assurance for
the Operational Phase Nuclear Power Plants."
GORB was established in accordance with requirements of TMI-1's technical specifications. It
was not required by TMI-2's technical specifications; however, its review responsibilities included
TMI-2.
The Chairman and Vice Chairman of GORB wereappointed by Creitz. The Chairman, J. Thorpe of
GPUSC, designated a minimum of four additional
members. No more than a minority of the committee had line responsibility for day-to-day operationof the Three Mile Island Nuclear Station.
The members of GORB collectively possessedknowledge of and experience in nuclear powerplantdesign, construction and operations, nuclear plant
management, industry organizations and practices,and B&W nuclear plant design and performance information. The majority of the members attended all
the meetings held by GORB for Unit 2.
GORB met at least once per calendar quarter
during the initial year of facility operation following
fuel loading and at least once every 6 months
thereafter. A quorum for informal meetings had nol ess than a majority of the principals or duly appointed alternates and included the Chairman orVice Chairman. No more than a minority of thequorum held line responsibility for day-to-day
operations at TMI.
GORB examined proposed changes in procedures and equipment, proposed changes intechnical specifications, violations of the operating
license (including technical specifications), operating
abnormalities and deficiencies, and reportable occurrences. It also evaluated the adequacy of the
Plant Operations Review Committee's and the Met
Ed technical support staff's determinations concerni ng unreviewed safety questions. GORB meetingsummaries do not indicate any review of the GRC
functions as they do for the PORC.

The Committee Chairman is empowered to senda letter to Creitz, within 14 days following completionof a review that would accomplish one of the followi ng:

tory; and problems, comments, and recommendations of the plant staff. Members of the review committee also participated in plant tours.
The Nuclear Plant Management Review Committee included Dieckamp, Creitz, Herbein, Arnold, andthe company presidents and generation vicepresidents from Penelec and JCPL. In preparation
for the TMI-2 review, the plant staff prepared anddistributed a package of material to each committee
member containing information for each item on theagenda. This information included comments byplant staff about their perceptions of problems invarious areas in addition to routinely distributed
copies of key letters on inspections, incidents, andother significant plant-related issues.
The management review for TMI-2 took place on
January 18, 1979. The information as outlined above
was presented to management by the plant staff.
The presentations appeared to be candid discussions of problems and suggested courses of action.
The main area of concern to plant management was
the lack of incentives to keep qualified personnel.
Also, filling of vacancies in certain positions was administratively cumbersome. Arnold, who attended
the meeting, recalled that two major decisions madewere to provide for a new service building (provide
centralized offices for plant staff) and authorization
to hire 6 to 10 more engineers. 9• Recommend actions that should be taken on pro-

posed changes to the operating license or technical specifications.
• Recommend actions that should be taken on proposed tests, facility changes, procedure changes,
or operating abnormalities that the committee hadreviewed.
• Recommend to the company President appropriate action to prevent recurrence of reportableoccurrences or to improve the effectiveness ofthe plant and corporate organization.

However, meeting minutes indicate that there
were never any recommended actions that required
the attention of Creitz, nor did GORB express concern about the dual responsibilities placed on Miller
or his lack of participation in PORC activities.
Furthermore, we found no evidence of concern
about the inexperience of two key individuals, Logan
and Kunder, in Unit 2 activities.
Nuclear Plant Management Review Committee

The purpose of the Nuclear Plant Management
Review Program was to provide senior managementi n the GPU system with a description of the overall
operation and status of the generating station inorder to annually assess the efficiency of thestation's performance. GPU President Dieckamp
set up this management review to ensure that theoverall operation and status of each nuclear plant in
the GPU system was reviewed annually by the Nuclear Plant Management Review Committee. The
stated objectives of these reviews were the followi ng:

d. Operational Quality Assurance Program
Another management overview tool was provided
by the Operational Quality Assurance (OQA) Plan.
Herbein, responsible for the implementation of thisplan, appointed George Troffer to head the OQA
program. Troffer was responsible for developing
the detailed program, updating it as necessary, andmonitoring all onsite and offsite activities required by
the program to ensure compliance with its requirements. Troffer also was responsible for the training
group at the TMI site.
Troffer coordinated his efforts with the GPUSC's
Manager of Quality Assurance in developing the details of the OQA Program for the Three Mile Island
Nuclear Station. This coordination was to ensurethat all of the GPU companies had the same basic
approach for their OQA Programs.
The TMI OQA Program is described in a quality
assurance plan that was reviewed and accepted by
the NRC. The purpose of the plan was to assign
and define responsibilities for implementing the requirements of NRC Regulation 10 C.F.R. 50, Appendix B, "Quality Assurance Criteria for Nuclear Power
Plants," and the Met Ed policy statement regarding
the OQA Program for TMI. Met Ed retained overall• To increase management awareness of nuclear
plant operational and safety problems.

• To promote intercompany communications on
nuclear matters.

• To provide management awareness of key nuclear personnel and related problems.

These objectives do not in any way reduce or replace the requirement of responsible line management to discharge their full responsibility for these
nuclear plants, nor of organizations established toi ndependently review nuclear plant safety-related
i ssues. 8

To help meet these objectives, onsite reviews
were conducted of plant organization and manpower; operational history and status; reported incidents; NRC inspections; personnel exposure his-

91 9

responsibility for all activities associated with thisprogram, and the work was performed either by Met
Ed personnel or by organizations or personnel performing services for Met Ed.
This program was primarily hardware and procedures oriented, and, although these features are
i mportant to nuclear safety, the program apparently
provided no insight into the management weaknesses developing in the Unit 2 organization.

TMI-2 site management organization resulting
from the organizational structure adopted during
the preoperational and power test phases andthe personnel changes effected at the start ofcommercial operation.
• Specific qualifications have not been established
for persons participating in onsite and offsite
safety review committees.
Recommendations

e. Summary of Findings andRecommendations• Prompt action should be taken to upgrade theFindings• I n December 1978, utility management staffed the

•
•

•

•

•

TMI-2 superintendent and superintendent oftechnical support positions with personnel having
li ttle experience at the TMI-2 facility. The incumbents met the standards established in ANSI
N18.1-1971 and the requirements of the NRC.
The qualifications and training requirements established by the NRC and industry standard N18.11971 for plant management personnel are inadequate.
Utility management did not adequately staff theUnit 2 superintendent position during the preoperational and power test phases in 1977 to
1978. The incumbent had dual responsibilities assite superintendent and Unit 2 superintendent.
This dual role was accepted by the NRC.
The Unit 2 superintendent's participation (by boththe incumbent and his designated replacement) in
the workings of the Plant Operations Review
Committee was infrequent during the criticalpreoperational and power test phases at TMI-2.
The management overviews afforded by onsite
and offsite safety review committees and the
Operational Quality Assurance Program were notadequately attentive to the qualifications andtraining of the TMI-2 management staff.
The offsite safety review committees should havediscerned the weaknesses developing in the

•
•

•

•

92 0

qualification and experience requirements for
personnel managing and supervising activities atnuclear powerplants. This action should include
establishing requirements for specific expertise in
the activity being supervised as well as experience at the nuclear powerplant where the activity
is performed. A suitable method of certificationof the qualification and experience requirements
should be established that will provide reasonable assurance that these personnel have andmaintain the skills needed to meet the requirements of their position. These actions should becompleted as soon as practicable but not later
than January 1, 1982.
The NRC should require that each key management position at a nuclear powerplant be staffedby a qualified person working full time in that position.
The NRC should perform a timely evaluation of
personnel changes in key plant management positions and changes in the plant organizational
structure to ensure that adequate staffing ismaintained.
Offsite safety review committees, or equivalent,should include within the scope of their activities
the evaluation of personnel changes in key
management positions and the evaluation ofchanges in plant organizational structure.
Qualifications for personnel participating on safety review committees should be established by
the NRC.

REFERENCES AND NOTES' Allenspach dep. at2

3
4

Seelinger dep. at

86.

615-16.

G.P. Miller dep. (Aug. 7,1979) at 54 (Pres. Com.).
Logan dep. at

Kunder dep. at

125-126.

Id. at 125-127.
3
Memorandum from H.M. Dieckamp, GPU Services, to
R.C. Arnold, S. Bartnoff, R.W. Conrad, W.M. Creitz, I.R.
Finfrock, J.G. Herbein, W.A. Verrochi, March 21, 1978.
9
Arnold dep. at 302-303 (Pres. Com.).
7

18 (Pres. Com.).

SLogan Interview Transcript at 28.

92 1

December 17,1968, the AEC published amendments
to 10 C.F.R. 50 based on the proposed amendments
to 10 C.F.R. 50 initially published August 16,1966.
A PSAR for TMI Unit 2 was submitted to the AEC
on March 10, 1969. The initial statement concerning"Emergency Drills" was identical to that submitted
for TMI Unit 1, except for minor grammaticalchanges. Also included was an outline of thespecific contents of the Radiation Emergency Plan
which was to be prepared.
On November 4, 1969, construction permit
CPPR-66 was issued by the AEC to authorize theconstruction of TMI Unit 2.
The Federal Register of May 21, 1970, reported
that the AEC had under consideration amendments
to 10 C.F.R. 50 that would require more information
pertaining to emergency planning. These amendments were to expedite the licensing process andprovide greater uniformity in plans submitted at thePSAR and FSAR stages. These amendments included Appendix E-Emergency Plans for Production and Utilization Facilities. The availability of a
Guide for Emergency Planning to assist applicantsin preparing the plans was also announced.
Amendments to 10 C.F.R. 50.34, published December 24, 1970, required that the information
presented in the PSAR and FSAR on emergency
plans address the items specified in Appendix E,
and incorporated Appendix E as part of 10 C.F.R.
50. The Guide to the Preparation of Emergency
Plans for Production and Utilization Facilities wasrevised effective December 1970. With the amendment of 10 C.F.R. 50.34 to incorporate Appendix E
and revision of the Guide, the final regulatory requirements affecting the TMI Unit 1 and 2 Emergency Plan were in place. These requirements were
not subsequently amended prior to March 28,1979.
The TMI Unit 1 FSAR was accepted for review on
March 2, 1970. As a result of the staff's review, theFSAR for Unit 1 was amended substantially. The
Unit 1 FSAR as finally amended included commitments from Met Ed to have a radiation emergency
plan as outlined in Appendix 12A to the FSAR and toprovide for coordination with local agencies for emergencies. The latter commitment addressed training and drills, emergency procedures, coordination
with and training of outside agencies, and the availability of medical consultants.
The Unit 1 FSAR "Radiation Emergency Plan"( Appendix 12A) was a document of 23 pages and 5
appendices, with a total of 7 pages, which was
responsive to NRC's requirements. This plan wasdeveloped from the initial commitment contained in
the May 3, 1967, PSAR. Final revisions were approved by the then Assistant Superintendent and7. THE RADIATION EMERGENCY PLANDEVELOPMENT AND TRAINING
a. NRC Requirements and Met Ed's Plan

Met Ed's radiation emergency plan in effect on
March 28, 1979, evolved from the emergency planning activities that began with the preparation of
their Preliminary Safety Analysis Report (PSAR) for
Unit 1. This report was docketed for review by the
Atomic Energy Commission (AEC) on May 3, 1967.
Publication of AEC requirements for emergency
planning at nuclear powerplants first appeared in
AEC's Notice of Proposed Rulemaking, Title 10 Codeof Federal Regulations, Part 50 (10 C.F.R. 50),
"Licensing of Production and Utilization Facilities,"
published in the Federal Register on April 15, 1955.
Pursuant to Part 50.34, applicants for a license toconstruct and operate a nuclear powerplant were to
submit the following:

A description of plans or proposals in the eventthat acts or accidents occur which would create radioactive hazards. The description should relate
the various operational procedures, the protective
devices, and the pertinent features of the site tosuch happenings as operational mistakes, equipment or instrument failure or malfunction, fire, electric power failure, flood, earthquake, storm, strikeand riot.

On August 16, 1966, the AEC published proposed
amendments to 10 C.F.R. 50. The proposedchanges included requirements for a "Safety
Analysis Report" in place of a "Hazard Summary
Report" and referenced a "Guide for the Organization and Contents of Safety Analysis Reports."
Furthermore, applicants for nuclear powerplant construction permits would be required to submit a
PSAR. A Final Safety Analysis Report (FSAR)
would be required before issuance of a license tooperate the plant. The FSAR would include "plansfor coping with emergencies..."On May 3, 1967, a PSAR was docketed for TMI-1.
The facility was to be operated by the Metropolitan
Edison Company. In a short paragraph in the PSAR,Met Ed stated that, (1) "... an emergency plan will be
developed...," (2) the emergency plan would coversuch emergencies as "fire, medical injury and illness, radiation, and contamination accidents, andother conditions that may result from nuclear andnon-nuclear accidents," and (3) station personnel
would be familiar with the emergency plan; practicedrills would be conducted for training; and outside
agencies included in the plan would be informed
concerning their expected roles in an emergency.
On May 18, 1968, construction permit CPPR-40
was issued for the construction of TMI Unit 1. On

92 2

the Radiation Protection Supervisor. The former, J.
Herbein, was to be Met Ed's Vice President of Generation at the time of the March 28, 1979, accident.
The AEC staff reported in the July 1973 Safety
Evaluation by the Directorate of Licensing that the
emergency plan was "... in conformance with 10
C.F.R. 50 Appendix E, Emergency Planning Requirements, and concluded that it is acceptable."
The operating license for TMI Unit 1, DPR-50,
was issued on April 19, 1974. Prior to the issuanceof this license, the Commission's inspection staff
found that Met Ed had satisfied the FSAR commitments for the development of emergency procedures. The Three Mile Island Radiation Emergency Plan for Unit 1 identified three categories of emergencies: local, site, and general. Included in thecriteria for declaration of a site emergency were: radiation level at the site security fence of "125 mR/h";l oss of primary coolant pressure coincident withhigh reactor building pressure, high reactor building
sump level, or both; and actuation of the reactor
building high range gamma monitor alarm. The criteria for declaration of a general emergency
category included a reactor building high range
gamma monitor indication of 8 R/h and a radiation
l evel at the site boundary of " > 125 mR/hr."b. Plan Changes from Licensing Unit 1 toMarch 28, 1979
The initial Unit 2 TMI Radiation Emergency Plan
was patterned after the previous plan for Unit 1, except for minor word changes, an increased numberof conditions resulting in a local emergency, and thechange in concept from a single unit site to a multiunit site plan.
On May 30, 1975, Met Ed submitted to the NRC
Amendment 28 to the Unit 2 FSAR in response toquestions from the NRC staff. Amendment 28 identified that there would be one supervisor of thechemistry and health physics staff for Units 1 and 2,
and that he or she would report to either the stationor unit superintendent, whoever was in charge. This
supervisor would be responsible for the chemistry
and radiation protection programs on site. The
amendment also contained as Appendix 13A a revised radiation emergency plan outline. The actionlevels for initiating a local, site, or general emergency remained unchanged from the Unit 1 FSAR, except for the addition of another condition for the declaration of a unit emergency.
In April 1974, the NRC's Regulatory Requirements
Review Committee, also known as the RRRC or the"Ratchet Committee," held its first meeting. One

function of the committee was to examine thenecessity for backfitting of existing plants to NRC
staff positions that were being developed on
acceptable methods of meeting NRC regulations.
Most of these positions were issued as regulatory
guides. At Meeting No. 31 in July 1975, a listing of
backfit categories was established: "Category 1Clearly Forward Fit only ... Category 2-Further
staff consideration of the need for backfitting
appears to be required ... and Category 3-Clearly
backfit."' The RRRC meeting No. 34, August 1975,
considered proposed Regulatory Guide 1.101 on
emergency planning and characterized this guide as
Category 3-Backfit required. 2 Decisions based on
the recommendations of the RRRC were announced
to applicants and licensees only through the implementation section of each regulatory guide. The
findings of the RRRC were distributed widely within
the NRC, particularly within the Office of Nuclear
Reactor Regulation (NRR). The RRRC had norequirement for followup to ensure that theirapproved recommendations were implemented. In
the case of the backfit requirement for Regulatory
Guide 1.101, it was the decision of the NRR Branch
Chief with the responsibility for emergency planningthat, because of the workload involved in backfitting
existing licensed plants and budgetary limitations,backfitting would be implemented on plants at theti me of review for issuance of an operating licenseor, if already licensed for operation, at a time in the
future when the licensee requested a change to thepreviously approved emergency plan.
Regulatory Guide 1.101 was issued in November
1975. Annex A, Organization and Content of Emergency Plans for Nuclear Power Plants, was used by
the NRC staff during their evaluation of FSARs.
Annex B, however, Implementing Procedures for
Emergency Plan, was published for comment.
I n September 1976, the NRC published the Safety
Evaluation Report (SER) for TMI-2. With respect toemergency planning, the staff stated that "...theapplicant has included plans for coping with emergencies in Appendix 13A of the Final Safety Analysis
Report. We have reviewed this emergency plan,submitted in Amendment 28." The staff closed withthe statement, "We conclude that it meets the requirements of 10 C.F.R. 50 Appendix E, is responsive to the specific requirements of the staff, andprovides a basis for an acceptable state of emergency preparedness."
Revision 1 to Regulatory Guide 1.101 was publi shed in March 1977. It incorporated certainchanges and the following statement.
[ The] guide reflects current Nuclear Regulatory
Commission practice. Therefore, except in those92 3

cases in which the applicant proposes an acceptable alternative method for complying with specified
portions of the Commission's regulations, themethod described herein is being and will continue
to be used in the evaluation of Final Safety Analysis
Reports.

The TMI procedure that
real-time detectors.
described response to a site emergency required
the dispatch of onsite and offsite monitoring teams.
When the accident occurred at the site at 6:55 a.m.
and general emergencies were declared at 7:24
a.m. on March 28, the first onsite confirmatory
measurement was reported at 7:46 a.m. The firstoff site confirmatory survey results were reported
from Goldsboro at 8:32 a.m. The elapsed time for
confirmatory surveys was 51 minutes for an onsite
location and 1 hour 37 minutes for Goldsboro. With
the wind existing on the day of the accident, a gas
cloud transport time to Goldsboro, about 1.4 miles
away, was 20 to 40 minutes.
Margaret Reilly, Pennsylvania Bureau of Radiation
Protection, was informed of a dose projection forGoldsboro of 10 R/h at about 7:45 a.m. Reilly advised the Pennsylvania Emergency Management
Agency (PEMA) of the potential need for evacuationof Brunner Island and Goldsboro. Reilly recalledthat it was not until about '/2-hour later that confirmatory offsite measurements established that dose
rates were near background levels in Goldsboro
and, consequently, the evacuation alert terminated.
Only an offsite, real-time detector system could
have provided the confirmation of offsite exposure
rates at a relatively inaccessible location such asGoldsboro within the 10 to 15 minutes that the Board
considered.
Contention 8 alleged that the warning and evacuation plans of the applicants and the Commonwealthof Pennsylvania were inadequate and unworkable.
The applicant's staff presented information concerni ng accident detection and evacuation, and emergency plan training and drills. The ASLB also heard
witnesses from State and local agencies and the
NRC staff. The Board considered the availability ofState and local officials, the appropriateness of the
response of such officials and the appropriatenessof the public response without prior tests or drills.
The Board found that Contention 8 was without
merit, that the staff had properly assessed the adequacy and workability of emergency response, andthat the emergency and evacuation plans were both
adequate and workable. We believe that the adequacy of State and local evacuation planning were
found to contain serious flaws in the days immediately following the accident and that these flaws
derived to a large extent from the belief that such an
accident was, if not impossible, at least so unlikely
as to be unworthy of consideration.
T. M. Gerusky, Director, Bureau of Radiation Protection, Commonwealth of Pennsylvania, stated thefollowing in response to questions:
Gerusky: I testified before the legislature trying to
get funds for our program ever since I have been

Before an operating license was issued to TMI-2
a hearing was held before an Atomic Safety andLicensing Board (ASLB). The ASLB's findings were
published on December 19, 1977. Two of thematters considered at that hearing concerned emergency planning. Contention 6 of that hearing stated
that, "The environmental radioactivity monitoring
program of the applicant's is inadequate to accurately measure the dose delivered to the public duri ng normal and accident conditions. Only active,
real-time detectors can determine what the actual
dose rate is. Furthermore, an array of offsite detectors could greatly aid possible evacuation plans."
The ASLB considered this as two separate contentions:

1. The actual radiation dose received by the publicduring normal and accident conditions can beproperly measured only if offsite, real-time detectors are deployed.
2. The implementation of evacuating plans could begreatly aided by the deployment of such detec3
tors.

With respect to the contentions, the ASLB foundthat the current monitoring capabilities were adequate based on a review of Met Ed's monitoring
capabilities, advantages, and disadvantages of active real-time detectors and the fact that Met Ed andthe NRC staff were. in agreement. Furthermore, theBoard found that the environmental monitoring program was not intended for evacuation planning or
implementation and that active, real-time detectors
would be of little or no value. The Board specifically
noted, "Instrumentation used to determine theseverity of an accident, and the need for any offsite
emergency action, is located on site and is monitored from the reactor control room." Furthermore,"in the event that accident conditions arose forwhich evacuation would be an effective protective
measure, necessary measurements and corrective
actions to mitigate the consequences, including notification of offsite emergency personnel, would be
performed quickly, within 10-15 minutes of the incident."4 The ASLB found the monitoring programs
adequate and that active, real-time detectors would
add nothing to the monitoring capability and would
not aid or improve the emergency response capabili ty.
I n examining Contention 6, we believe the ASLB
viewed too narrowly the potential use of offsite,924

with the State to get a good emergency response
capability including radios and communications andso forth.
Question: This is communications, van, people...

i nterface for Met Ed with the NRC. Consistent withthe applicable regulations, 10 C.F.R. 50.59, GPUli censing did not believe that NRC staff approval
was required prior to implementation of the revised
plan. When the revised emergency plan was submitted to the NRC, it was identified as Amendment
65 to the TMI-Unit 2 FSAR, and was directed to the
NRC licensing project manager with a letter dated0
May 11, 19781 This submission was considered by
GPU licensing to be for information and not a formal
request for approval by the NRC.

Gerusky: Equipment.
Question: Portable iodine equipment?

Gerusky: Right. And they look at you and say,
' For reactor accidents? No way!' Rasmussencame out and said that the probability was greaterof getting killed by a meteorite. You haven't been
killed by a meteorite. 5

On February 8, 1978, License DPR-73 wasi ssued to Met Ed for the operation of TMI, Unit 2. At
this time the NRC-accepted emergency plan wasi dentified as a part of Amendment 28 to the FSAR,
dated May 30, 1975. Met Ed's Supervisor of Radiation Protection and Chemistry, Richard Dubiel, was
the individual with overall responsibility for the radiation emergency plan.s's Dubiel reported to the Station Manager, Gary Miller, in both the normal andemergency organizations. In the latter part of 1977,
a health physics engineer was employed, reporting
to Dubiel, who was assigned the principal task ofrevising and updating the existing emergency plan.
The engineer functioned as an emergency planning
coordinator, a position which was not formalizedprior to March 28, 1979. Working with a consultant,a revised emergency plan and procedures based on
the requirements contained in Regulatory Guide 1.101
were developed. During the preoperational period,
1977-78, the NRC Region 1 inspection staff discussed with Met Ed representatives the content of
the Radiation Emergency Plan and Procedures. Thei nspection staff was concerned that the plan outline
i n Appendix 13A to Amendment 28 of the FSAR was
not state-of-the-art. 9 In January 1978, the newly
revised emergency plan and procedures were discussed by Met Ed personnel with NRC Region 1
i nspectors. Met Ed's emergency planning coordinator understood that the NRC inspector review of theemergency plan and procedures conformed to theguidance contained in Regulatory Guide 1.101. In
January 1978, after review by Dubiel, the revisedplan and procedures were submitted to the Plant
Operations Review Committee (PORC). The revised
emergency plan had been designated as the Three
Mile Island Emergency Plan 1004, a plant procedure.
The implementing procedures were designated as
1670 series procedures. At meeting No. 250, January 1978, PORC recommended that the unit superi ntendent approve the new and revised emergency
plan and procedures.
Following the approval of the emergency planand procedures, copies of the revised plan were
provided by Met Ed to the General Public Utilities( GPU) licensing group that provided the licensing

Unknown to the licensee, the submission of anamendment to an FSAR-described emergency plan
resulted in a review of the plan pursuant to the earli er NRC position to backfit the requirements ofRegulatory Guide 1.101. When the staff received therevised emergency plan, they found that the plan
did not fully conform to the staff position as statedin Regulatory Guide 1.101, Revision 1 and was, therefore, not acceptable. In a staff memorandum dated
November 1, 1978, the NRC reviewer stated, "Theli censee should be instructed to revise the submittal
to conform to Regulatory Guide 1.101, Revision 1, andin the interim, to abide by the provisions of theemergency plan previously approved as stated in
the Safety Evaluation Report for Three Mile Island
Unit 2, dated September 1976." h 'No action was taken by the NRC with respect tonotifying Met Ed or GPU of the staff's position on
the emergency plan with respect to Regulatory
Guide 1.101. As of March 28, Met Ed, not having
heard to the contrary, believed that the emergency
plan in effect was that contained in Amendment 65
to the FSAR. It was this plan on which Met Ed
based their response to the accident.
c. The Emergency Plan in Effect on March 28,
1979
Appendix 13A, Three Mile Island Site Emergency
Plan, submitted as Amendment 65 to the FSAR, isorganized substantially on the same format as Regulatory Guide 1.101, Annex B. Dubiel stated that
Met Ed rewrote their emergency plan using Regulatory Guide 1.101 as a basis, and that they attempted
to make the old and new plans compatible becauseof the training that had already been accomplishedunder the original plan. The review of the submittalby the Environmental Evaluation Branches, Divisionof Operating Reactors, Office of Nuclear Reactor
Regulation, had identified areas where the discussion of certain elements of Regulatory Guide 1.101
was either deficient or missing. The NRC staff did
not notify Met Ed or GPU of their findings. Some
92 5

decontamination of personnel and of vehicles
evacuating from the site."

NRC findings that were of significance during or following the accident of March 28 were:• Your classification system does not include an

Certain other information identified as missing or
i ncomplete was in Met Ed's possession but had notbeen included in the submittal.
An unannounced inspection of emergency
planning was conducted at TMI-1 and TMI-2
by an NRC radiation specialist in July 1978. Thisi nspection included an examination of revisions toemergency plan implementing procedures. The
revisions were found to provide the same or higher
degree of preparedness than the previous procedures. The licensee had satisfied the administrative requirements for procedure changes. Additionally, the licensee conducted several emergency plan
drills during the latter part of 1978. One of thesedrills was observed by NRC inspectors. As a resultof observations during the drill and discussions with
the NRC inspectors, portions of the emergency procedures were revised early in 1979. These revisions were subsequently reviewed and approved inaccordance with the licensee's procedures.
Met Ed's radiation emergency plan in effect on
March 28, 1979, was part of Station Administrative
Procedure 1004. This procedure included guidance
and procedures pertinent to the plan and defined
three types of emergencies:

Emergency Alert Class as described in Regulatory Guide 1.101 at Section 4.1.2. A site emergency includes a condition of 125 mR/h at the
security fence. Such a dose rate must be theresult of a serious incident requiring a General
Emergency response.
• Your listing of a Spectrum of Postulated Accidents in Section 2.2 should include instrumentation capability for prompt detection and continued assessment and manpower needs in relation to the anticipated sequence and timing of
events.
• Section 4.2, Assessment Actions, of your plan
places emphasis on in-plant radiation monitorsand on and offsite surveys, but makes no mention of process instrumentation. Section 4.1.5 ofRegulatory Guide 1.101 states that 'emergency
action levels and other criteria for declaring a
General Emergency should be specified in termsof information readily available in the control
room. Such information should include thestatus of engineered safeguards.' As backup tosuch installed instrumentation your plan should
i nclude estimated dose rates at a convenient location outside containment, e.g., opposite theequipment hatch or outside the personnel airlock, for the following:( a) release of primary coolant activity into
containment(b) release of core gap activity into containment(c) release of activity from 1% core melt into
containment(d) release of activity from 10% core melt into
containment• Activation criteria for declaration of emergencies
should be defined in terms of control room instrument readings and should also be related toprotective action guides incorporated in USEPA
guidance. (Regulatory Guide 1.101, Section

1. Personnel or Local Emergencies are accidents ori ncidents involving one or more individuals and/or
protective evacuation of one or more buildings. A
personnel emergency may require local offsite
services such as fire, police, ambulance, or medical.
2. Site Emergencies are accidents or incidents withthe potential for uncontrolled release of radioactivity to the immediate environment. Site evacuation by nonessential personnel may be required.
This emergency constitutes a potential for offsite
radiological exposures.
3. General Emergencies are accidents or incidents
with potential serious radiological consequences
for the health and safety of the general public.
Coordination with offsite support agencies is initiated to provide for protective actions.

4.1.4.)• Sections 4.3.1 and 4.3.2 of your plan should be

expanded to include the following information
specified under Section 6.4 of Regulatory Guide
1.101:(a) steps to provide visitors to the plant andto make available to occupants in the low
population zone information concerning
how the emergency plans provide for notification to them and how they can expect to be advised what to do.
(b) the means and the time required to warn
or advise persons in the low populationzone.
(c) protective actions including isolation andarea access, control of agricultural andwater supplies, and the criteria for suchactions ... 2• Section 4.4.2 states that first aid and decontamination facilities are maintained at the Unit 4.1
ECS (Emergency Control Station) and the twoservice buildings. Your plan should also
describe provisions for first aid, monitoring and

The plan contained the following:

1. A section on Organizational Control of Emergencies describes the onsite emergency organization, staffing and responsibilities, and provisions
for augmentation of the onsite organization byvarious offsite groups.
2. A section on Emergency Measures describes thedelegation of authority to declare an emergency
and provides for notification of station personnel
and state officials. The plant monitoring systems
92 6and on- and offsite monitoring are described withrespect to assessment actions.
Protective
actions, aid to affected personnel, emergency
exposure criteria, first aid and decontamination,
medical transportation, medical treatment, andbackup medical treatment are also included.
3. A section on Emergency Facilities identifies theaffected unit control room as the Unit 1 and 2
Emergency Control Centers. The unaffected unit
control room is identified as the Alternate Emergency Control Center. The Emergency Control
Station for either unit is located in the radiation
protection laboratory of Unit 1 with an alternate
location in the Unit 2 Shift Supervisor's office.
The offsite Emergency Control Station is identified as the TMI Observation Center. Communications systems are identified, as are natural
phenomena and radiological, nonradiological, andenvironmental monitoring equipment and systems. Damage control equipment is identified.
4. A section on Maintaining Emergency Preparedness identifies groups requiring specialized traini ng and provides for training program administration and emergency plan drills as a means oftesting equipment and personnel familiarity withassigned duties. Drill types, purpose and frequency are identified. Critiques are required foll owing drills.
5. A section on Recovery and Reentry addresses
general considerations on recovery, emergency
exposure guidelines, and reentry.
6. A section on Written Agreements for the Coordination of Emergency Planning states that writtenagreements have been reached with various
local, State and Federal agencies that ensure aclear understanding of responsibilities and proper
coordination of activities, and identify the type of
support to be provided.

The second volume of Met Ed's Station Administrative Procedure 1004 included a Radiation Emergency Checklist, an abbreviated instruction for use
by plant personnel to ensure that required actions
were completed; a procedure for Recall of Standby
Personnel to Plant; and two procedures concerning
the plant communications systems. The emergency
plan implementing procedures developed by Met Ed
addressed those topics identified in Annex B toRegulatory Guide 1.101.
Met Ed's administrative procedures and operational quality assurance plan provided a mechanism
for procedure review and approval; specified a procedure review frequency; and provided for procedure revision, review, and approval.
Theseadministrative procedures were required by theplant technical specifications. Procedures in effect

92 7

at the time of the accident had been reviewed andapproved in accordance with Met Ed's procedures.
Revisions to procedures can be initiated by Met
Ed supervisors on the TMI station staff but are subject to review by PORC. Prior to the accident, it
was not required that revisions to radiation emergency plan procedures be referred to the acting
emergency plan coordinator. They would havecome to his attention only if he had been a memberof the PORC when the revision was reviewed. 13
d. Training Philosophy-Classroom vs. Drills
The section of the plan entitled "Maintaining Emergency Preparedness, Personnel with Emergency
Responsibility" states:
Members of the Three Mile Island staff having
responsibilities in relation to the Emergency Plan
will be required to participate in appropriate training
programs or drills. Certain off-site agencies withemergency responsibilities will also be invited toparticipate i n appropriate training programs anddrills conducted at TMI.

The various training programs were to provide program participants with the necessary information toensure continued effectiveness of the plan whencombined with the required drills.
e. Training-Goals vs. Accomplishments
The members of the TMI staff assigned specificemergency roles required training appropriate to theassignments. The training programs were to be
conducted annually. The supervisor of training was
assigned the responsibility for scheduling, instructor
assignments, and training documentation maintenance. The training department did not have qualified instructors in the areas of specialized instruction necessary and was dependent upon personnel
from other onsite groups for the preparation of lesson plans and for instructors.
Procedure 1670.9, "Emergency Training and Emergency Drills," specified the employee classificationthat could be called upon to fill any of the specificcategories in the emergency response organization.
The procedure further specified that all members of
the staff were required to be familiar with their duties and responsibilities. As originally issued, theprocedure required training of all individuals who
might be called upon to fill one of the emergency
categories. Although the emergency training wasoffered annually, an individual who was trained andqualified one year retained that qualification
throughout the following year. The training pro-

cedure was developed in response to Regulatory
Guide 1.101. During 1978, Met Ed attempted to satisfy the training requirements contained in the procedure.
I n early 1979, the procedure was revised to avoid
a situation in which noncompliance for failure to follow procedures was inevitable. The change in procedures occurred after discussions with NRC inspectors who questioned
the licensee's training ac14,15
complishments.
As originally prepared, the procedure called for 100% training of personnel thatmight be assigned to emergency response roles.
The training department found, however, that theirlack of authority to obtain the required lesson plans
and to control trainee attendance made the goal
unachievable. Correspondence from the training organization to various onsite organizations during theperiod April 1978 to February 1979 identified an increasing concern regarding the inability to accomplish the training. 16 As a result, in February 1979,
Procedure 1670.9 was amended to remove the
100% training requirement and instead place a limitation on personnel assignments. This change stated that only those individuals who had received theappropriate training were to be assigned to the foll owing emergency response categories:
Accident Assessment Personnel
Radiological Monitoring TeamFire Brigade Team
Repair Party TeamFirst Aid Rescue TeamThe imposition of this limitation on assignments
required a plant roster that identified the emergency
training each individual had received. Additional
information not contained in the roster was locatedin training records. This information, as of March 1,
1979, is summarized in Table 111-2.
Procedure 1670.9 also provided for training ofoffsite emergency personnel. On October 12, 1978,
training was conducted for offsite agencies andorganizations, including:Company No.1, Rescue Hose Company No. 3, Bainbridge Fire Company, and Liberty Fire Company.
Judged on the basis of the early philosophy of
100% training, the licensee was not totally successful in his training of plant personnel. The failure was
not numerically significant, except in the case of
repair party team training. Met Ed's training personnel said that the repair party team training deficiency resulted from a misunderstanding. The personnel trained were mechanical maintenance personnel
only; i nstruments and controls, and electricalmaintenance personnel did not receive any training.
The nature of the misunderstanding was communicated to G. Miller, Station Manager, in February
1979. However, corrective action had not been accomplished at the time of the accident. Additional
repair party team training was conducted in January
1979, but the instructor was not familiar with thematerial presented and the training was, therefore,
not credited.
The emergency plan stated that site or generalemergency drills would be conducted annually, consistent with Regulatory Guide 1.101. The drill program conducted by the licensee in 1978 included
seven drills. The seventh drill was observed by
NRC inspectors. The drills were of varied scenarios
and included situations which, while unbelievable
during the drills, actually came to pass during theaccident. Some of the staff believed the drills wereunrealistic because of the simulated high radiation
l evels and other data with which they were provided
during the drills. A frequent comment was that thisbelief disappeared on March 28.
During their inspection of the seventh drill, the
NRC inspectors identified no noncompliance. However, they did discuss records of times at which radiological measurements were taken and the "use ofexisting procedures to project thyroid critical pathdoses prior to receipt of environmental air sample
results."

Porter-Gertz Consultants
Pennsylvania Bureau of Radiation Protection (BRP)
Pennsylvania State Council of Civil Defense(now PEMA)
Londonderry Fire Company
Goldsboro Fire Department
York Haven Police Department
Susquehanna-York Haven Fire Department
Dauphin County Office of Emergency Preparedness
Pennsylvania State Police (PSP)f. Training EffectivenessOn the day of the accident some personnel wereassigned to radiation monitoring and repair party
teams who had not been trained for the duties towhich they were assigned. In addition, certain of
the training provided was inadequate. Radiation
monitoring teams were required to use a gamma
scintillation detector, dual-channel analyzer (Eberline
Instrument Company, Stabilized Assay Meter SAM2/RD-19) to measure the radioactivity in air samples. Several Met Ed rad chem techs expressed

On December 5, 1978, the annual training session
for local fire companies was conducted. A total of
28 representatives attended, including representatives of Londonderry Fire Company, Union Hose
928

TABLE 111-2. Plant roster of emergency training received by Met Ed employees
Employees in
Category

Category
Employees
TrainedNoncategory
Employees
TrainedGroup 1: Supervisor of Operations,
Shift Supervisors, Shift Foremen,Control Room Operators

53

49

18 in BothGroups 1&2

Group 2: Supervisor - Radiation Protection & Chemistry, Radiation Protection Foremen, Rad Chem Techs,
ShiftSupervisors,
NuclearEngineers

28

25

-

Rad Chem Techs, Auxiliary Operat ors "A"

51

45

42

Maintenance Shift Workers (designated by Supervisor of Maintenance)

40

19

-

Aux. Operators, Rad Chem Tech Jrs.

87

84

274

First
Aid/Rescue
Team

Rad Chem Techs, Auxiliary Operators "A"

51

50

1 68

Supervisor of Operations, Shift
Supervisors, Shift Foremen, Control
Room Operators, Aux. Operators

1 36

1 36

-

Training
Program for
Plant Security Personnel

Supervisor - Plant Security, Security
Sargeants, Security Guards

48

45

-

EmployeePosition

Emergency
Director
Accident
Assessment
Personnel

Radiation
Monitoring
Team

RepairParty TeamFire Brigade
Team

Training
Program forOperations
Personnel( Emergency
Plan)

Employee Category

Station and Unit Supt., Unit Supt. Tech. Support, Supervisor of Operations, Shift Supervisors, Shift Foremen

28

25

6

Notwithstanding the aforementioned shortcomi ngs, we believe that the response of plant personnel to the radiation emergency resulting from theaccident at TMI-2 was reasonably effective. Frequently during interviews, Met Ed personnel statedthat the response to the radiological emergency had
been good and that it had gone unrecognized. They
attributed the success of the response to the drills.
The drills provided valuable training that resulted
in speeding the dispatch of offsite teams, improved
accountability, personnel familiarity with emergency

concerns about the training prior to the accident.
Although training was provided, the training and limited opportunity to become familiar with the SAM-2
i nstrument seemed inadequate. An individual experienced with instruments stated that an electronics technician in his employ became competent in
the use of the instrument after "playing" with one for
40 to 50 hours. 17 Although probably extreme, thisexample tends to indicate that a demonstration or
li mited use during a short classroom session or drilli s insufficient.
92 9

roles, practice in unusual evolutions, personnel famili arity with the potential for high dose rates and airborne levels and, in general, improved ability torespond to an accident.

h. Summary of Findings andRecommendations
Findings

Had the licensee been content only to satisfy therequirements of Regulatory Guide 1.101 and of the
TMI Emergency Plan for one site or general emergency drill each year, the licensee would have beenless able to mount an effective response.

• The criteria included in the emergency plan for

declaration of a site emergency were nonconservative and no emergency alert classification wasi ncluded. These deficiencies were recognized by
the NRC but were not communicated to Met Ed.
These deficiencies could have delayed both theidentification and declaration of the emergency.
• The possible value of active, real-time, on-andoffsite monitors during an accident was an issue
considered and rejected during the TMI Unit 2
prelicensing hearings.
• A training program that included seven emergency plan drills held shortly before the accident,
and which also attempted to provide training for
all personnel with emergency response assignments, significantly aided in the ability of the plantstaff to respond to the accident.
• The importance assigned to emergency plan
training by the TMI supervisory staff was lessthan warranted; furthermore, when training inadequacies were identified by plant staff members,corrective actions were only marginally effective.
• The present Regulatory Guide 1.101 position,
which provides for one drill prior to initial fuell oading and annual drills thereafter, is not adequate to provide for the level of training andpractical experience required to respond to amajor accident.
• I nadequacies in the TMI emergency plan andpreparations are attributable, in part, to the low
priority placed on those subjects by the NRC.

g. Offsite Agencies-Training and Interface
State and local agencies participated in training
and drills conducted by the TMI staff. Reports ofcommunications on March 28, 1979, between Margaret Reilly, Chief, Division of Environmental Radiation; and W. Dornsife, Nuclear Engineer, Bureau of
Radiation Protection; K. Molloy, Director of Emergency Preparedness for Dauphin County; and R.
Dubiel, Supervisor, Radiation Protection and Chemistry, TMI; show that the individuals knew one
another and had knowledge of Met Ed's radiologicalemergency plan.

The following extract of a transcribed telephone
conversation between Dubiel and Molloy during themorning of March 28 demonstrates the working relationship between the site and local agencies in thei mmediate area.
Dubiel: Kevin - Dick Dubiel. Okay, we are in for
real.
Molloy: Okay.

Dubiel: Okay, it looks like - we are not exactly
sure. We've got the core covered right now. I
don't think we've got a real big problem, but we've
got some bad radiation readings that could, in fact,
be erroneous, but we can't rely on that, okay. Uh,what I need is, I need to get Maggie Reilly [BRP],
the foreman, back in touch with us.
Molloy: Okay, ... we'll take care of it 18

Recommendations• Regulatory Guide 1.101 should be revised to in-clude a requirement that each nuclear utility employee with an emergency response assignment
receive appropriate training and participate in atl east one emergency plan drill each year.
• The NRC should expedite review and upgradingof existing emergency planning and preparation
requirements.

Met Ed had conducted training and orientation
programs and provided the opportunity for participation in drills to the State and local agencies. Met
Ed had apparently satisfied any outstanding commitments to the State and local agencies in the areaof radiological emergency response planning.

93 0

REFERENCES AND NOTES'Memorandum from E. G. Case, NRC, to L. V. Gossick,"Regulatory Requirements Review Committee Meeting No.
31," July 11,
2
Memorandum from E. G. Case, NRC, to L. V. Gossick,"Regulatory Requirements Review Committee Meeting No.
34," August 22, 1975.
3
E. Luton, E. O. Salo, and G. A. Linenberger, "Atomic
Safety Licensing Board - 6 NRC 1185 (1979)," p. 1201,
Docket 50-320, December 1977.
4!d. at 1202.
5
Gerusky dep. at 42-43.
6Herbein dep. at 98-101.
7
Landry Interview Memo at 1.
aDonaldson Interview Memo at 1.
9"Memorandum (and attached report) from G. Knighton,
NRC, to R. Reid, "Three Mile Island Revised Emergency
Plan," November 1, 1978.
12
Id. at Enclosure 1.
13
Landry Interview Memo at 5.
14
14. at 4-5.
15
McCormick Interview Memo at 1-2.
1aCorrespondence and records of telephone conversations from F. McCormick, TMI, to various members of
the TMI staff, April 5, 1978 to February 14,1979, concerning training.
17
Jacobs Interview Memo at 3.
18
lnspection and Enforcement: Telephone Call Transcript, R. Dubiel, TMI, to K. Molloy, Dauphin County;
March 28,1979, TMI tape No. 210.

Id. at 3.
Tsaggaris interview memo at 2.

10

93 1

B NRC RESPONSE
the Maryland suburbs (see Figure 111-9). Each Commissioner has "equal responsibility and authority inall decisions and actions of the Commission." Thechairman of the five-member commission is "theprincipal executive officer" and exercises "all of theexecutive and administrative functions of the Com2
Although the precise authority of themission."chairman when compared to the other four Commissioners seems unsettled, Commissioner Kennedy
interprets it thus:

1. INTRODUCTION
This section of Volume II deals with the responseof the Nuclear Regulatory Commission (NRC) to theaccident at Three Mile Island (TMI). The section begins with a brief background of some of theagency's primary performers during the TMI emergency, outlining their roles in the NRC's organizational structure; then it considers the NRC's emergency response structure as described in agency
documents when the accident began. A narrative
account of selected aspects of the NRC's actual
emergency response follows this introduction. The
narrative account focuses primarily on the first 5days of the accident. This account, designed as avehicle for evaluating the quality of the agency's
response, is immediately followed by the evaluation.
A summary of recommendations concerning theagency's emergency response is provided in Section III.B.3.c.
This section does not focus on the NRC's relationship with the media during the accident at TMI.
That subject is discussed in Section III.D.

I' m a 20 percent shareholder.... The 20 percent
that I'm talking about is 20 percent of perhaps 90
percent. I have 20 percent of all of the substantive
questions and issues that are the responsibility of
the agency.
But I don't have 20 percent of the execution
responsibilities. Those things are a matter ... for
the Chairman to execute.3

Until recently, Joseph Hendrie served as Chairman of the NRC. Hendrie, unlike the other fourCommissioners, previously held senior staff positions within the agency. 4 Hendrie has more substantial expertise concerning nuclear reactor systems than any other Commissioner. On the third
day of the TMI accident, former Chairman Hendrie
took an active role in managing the agency's emergency response and was a prime motivator of the
NRC's efforts to determine whether the hydrogen
bubble lodged in the reactor vessel was potentiallyexplosive. The roles played by the other Commissioners during the TMI accident varied widely, but
none of the other Commissioners were as directly
i nvolved as Hendrie in managing the NRC response.

The NRC's Principal Emergency Response Cast and
Their Roles in the Daily Organization

The NRC is headed by five CommissionersJohn Ahearne, Peter Bradford, Victor Gilinsky,
Joseph Hendrie, and Richard Kennedy. Their offices are located on H Street in downtown Washington, D.C., 5 miles from most of the agency's staff
personnel, who work in offices scattered throughout
93 3

FIGURE 111-9. NRC Headquarters Locations

sons. The Division of Operating Reactors also is
responsible for analyzing operating events and ensuring that these experiences are taken into account in the licensing process.
On March 28, Victor Stello, Jr., was Director ofthis Division and Darrell Eisenhut was his Deputy
Director. Both have principal expertise in reactor
systems. During the first days of the TMI accident,
Stello was a designated member of the Incident
Response Action Coordination Team (TRACT), which
was the principal supportive arm of the EMT. Stello
generally supervised all NRR staff members who
worked for IRACT during the beginning of the accident. Because of his expertise, however, Stello
was more directly involved in IRACT's evaluation ofreactor systems data.
At the time of the TMI accident, Richard Vollmer
and Brian Grimes served as Assistant Directors
under Stello and Eisenhut. Vollmer was chosen tolead the first team of NRC officials sent from Headquarters to the site on March 29. Grimes, a radiology specialist who had done a great deal of work inradiological emergency response planning, worked
at Headquarters for IRACT. Grimes was assignedby Stello to take direct charge of the NRR members
who were evaluating radiological data.
A second major office within NRC is the Office ofInspection and Enforcement (IE). IE personnel arel ocated in the East-West Towers building in Bethesda, Md., which is approximately 1 mile from the NRR(Phillips Building). During the TMI accident, theHeadquarters emergency response generally was
managed from an Incident Response Center locatedi n the East-West Towers building.
The IE's principal responsibilities are to inspect
reactor facilities both during construction and after
the facilities are completed and licensed to operate.
The IE also ensures compliance with NRC licenses,
rules, and regulations. The IE personnel spend
more time "in the field" than NRR personnel because
of inspection functions. When IE officials identify either a need to change the terms of a reactor
operating license, or a problem in interpretation of
the license, the matter is referred through IE officials
at Headquarters to the NRR where final decisions
concerning the license are made. Many NRR officials seem to consider themselves more technicallytalented than IE officials and in at least one respect
NRR is treated as a more important office than IE.
The Energy Reorganization Act of 1974, as amended, positions the director of NRR one executive
grade level above the level of the IE director. 8
On March 28, 1979, John Davis was Deputy
Director of IE. The director's position was then vacant (and had been for about a year) so Davis also

The NRC's emergency response during the TMI
accident involved many but not all of the agency's
staff level offices. Figure 111-10 displays the organizational structure of the NRC, truncated to show thestaff offices that played a significant role in the
response. Figure III-11 repeats this organizational
display to show some of the principal emergency
response personnel from NRC Headquarters in theirnormal organizational positions during the accident. 5
This discussion will focus principally on two staff
offices-the Office of Nuclear Reactor Regulationand the Office of Inspection and Enforcement.
By statute, the Office of Nuclear Reactor Regulation (NRR) is responsible for licensing and regulating
all facilities associated with the construction andoperation of nuclear reactors. The NRR personnel
are located in the Phillips Building in Bethesda, Md.,
about 20 to 25 minutes travel time from the Commissioners' Washington, D.C. offices. The NRR reviews the safety of all such facilities by "monitoring,
testing, and recommending upgrading of systems
to6
prevent substantial health or safety hazards."
Harold Denton is the Director of the NRR and Edson Case is Denton's Deputy Director. During the
TMI accident, Denton and Case each served at different times as a member of the Headquartersbased Executive Management Team (EMT), which
was assigned responsibility for managing theagency's emergency response. On the third day,
Denton was rushed to the site to take onsite command of the NRC's effort.
Of the four divisions within the NRR, the two ofprimary interest are the Division of Systems Safety
and the Division of Operating Reactors. The Division of Systems Safety is responsible for reviewing
and evaluating most of the engineering aspects ofevery application for a reactor construction permit
or a reactor operating license. Roger Mattson is
Director of this division within the NRR. Presumably
because of his position, one newspaper reportingon the accident at TMI described
Mattson as "the7
NRC's top safety expert."
Mattson had no assigned role at the beginning of the accident, but hesoon became responsible for a wide range of theagency's technical support efforts, including its illfated attempt to determine the potential hazards ofthe hydrogen bubble.
The second division within the NRR, the Divisionof Operating Reactors, is responsible for reviewing
and evaluating proposed design and operationalchanges at a reactor facility after the reactor islicensed. However, in the case of the TMI-2 reactor, which had been licensed for more than a year,
the Division of Operating Reactors had not yet taken over this responsibility for administrative rea93 5

FIGURE III-11. Simplified NRC Organization Chart
but as matters evolved, he divided his IRACT
responsibilities with Stello. Moseley headed IE staff
members involved in the Headquarters emergency
response, and Stello was in charge of NRR personnel. Both Stello and Moseley have principal expertise in reactor systems, and during the TMI accident
Moseley was involved more directly with IE personnel who worked on that aspect of the accident. The
IE personnel principally gathered reactor systems
information from the site and referred the information to NRR reactor specialists for evaluation.
The IE Division of Fuel Facilities and Materials
Safety Inspection is responsible for conducting
safety inspections of all reactor facilities. Most of
the division's members specialize in health physics

served as Acting Director. (Since the TMI accident,
Stello has been appointed Director of IE.) As Acting
Director, Davis also was a member of the
Headquarters-based EMT during the accident.
Four divisions exist within IE. Two are of interest,
the Division of Reactor Operations Inspection andthe Division of Fuel Facilities and Materials Safety
Inspection.
The Division of Reactor Operations Inspection is
responsible for inspecting reactor systems once
they are licensed. This division is the IE counterpartof the NRR's Division of Operating Reactors. On
March 28, 1979, Norman Moseley was Director.
During the emergency, Moseley was designated toact as "Director" of the Headquarters-based TRACT,
93 7

matters. James Sniezek is Director of this division.
During the TMI emergency, Sniezek supervised IE
personnel at Headquarters who worked for IRACT
on the radiological aspects of the accident.
Sniezek's personnel primarily gathered radiologicalsurvey data from the site and then referred this information to NRR members for calculations andevaluation. 9
The Office of Inspection and Enforcement also includes five regional offices located throughout theUnited States. The Region I office sent the NRC's
i nitial emergency response team to Three Mile Isl and. Figure 111-12 displays pertinent parts of Region
I' s organizational structure to show some of theprincipal NRC emergency response personnel from
Region I in their normal organizational position during the accident.
On March 28, 1979, the Director of Region I wasBoyce Grier and James Allan was Grier's Deputy.
As an IE staff member, Grier's communications with
Headquarters during the TMI crisis were generallywith IE officials such as Moseley and Davis rather
than with NRR officials such as Stello or Denton.
Grier had overall supervisory authority over the initial emergency response team sent to the accident,
but he personally did not go to the site until midday
Friday.
The Region I office has four branches. The duties and functions of these branches generally coincide with those of IE's four divisions at Headquarters. The two of interest are Region I's Fuel Facilities and Materials Safety Inspection Branch, thecounterpart of Sniezek's Division at Headquarters,
and Region I's Reactor Operations and Nuclear
Support Branch, the counterpart of Moseley's Division at Headquarters. George Smith directs Region
I's Fuel Facilities and Materials Safety Inspection
Branch. Eldon Brunner supervises its Reactor
Operations and Nuclear Support Branch. Neither
Smith nor Brunner went to Three Mile Island until
Friday, March 30, when Smith joined the onsite
team. Instead, they remained at Region I "coordinating" the radiological and reactor operations efforts. As Figure 111-12 shows, all of the Region I personnel who went to the site on Wednesday or
Thursday normally worked under Brunner or Smith
in Region I offices.
The daily affairs of the entire NRC staff aremanaged by an Executive Director for Operations(EDO). The EDO is appointed by and serves theCommission. As with the NRR and IE directors, theEDO works in a separate office building in Bethesda, Md., 5 miles from the office of the Commissioners. Although directors of major offices such as

93 8

NRR and IE are required to keep the EDO "fully andcurrently informed" concerning communications with
the Commission, these office directors report directly to the Commission, not to the EDO. Moreover,
the Commission, not the EDO, has the power to hire
and fire the major office directors. Lee Gossick, thepresent EDO, says that the function of this positioni s to ensure that the other offices are working in acoordinated fashion. 10 Gossick served as amember of the EMT during the accident and was byformal designation the EMT's "Director."
I n the NRC's normal organizational configuration,
a number of offices that are smaller than IE andNRR report directly to the EDO. One such office is
the Office of State Programs, which is responsible
for cooperating with the States on nuclear licensing
and for assisting State and local authorities in the
preparation of emergency plans. On the third dayof the accident, when the EMT hastily decided torecommend evacuation from the area of the TMI
plant, an official from the Office of State Programs,
Harold Collins, was given the task of calling State
officials to transmit the NRC's recommendation.
The preceding is not intended to be a complete
description of the NRC organization and its functions.
The Agency's Written Emergency Response Plans
The NRC has a series of documents providing instructions on how the agency should respond to an
emergency. Pertinent documents include (1) NRC
Manual Chapter 0502, NRC Incident Response Program, which provides the foundation for all agency
response planning; (2) a Headquarters Incident
Response Plan, the most complete text dealing withthe emergency response of NRC personnel at
Headquarters; (3) various Incident Response Procedures, which are prepared by and for divisions
within the Office of Inspection and Enforcement; and(4) a Region I Incident Response Plan, which isprepared by and for IE's Region I personnel. These
documents are not always consistent, but the outli ne of the NRC's emergency response organization
emerges from them. What follows is a discussion ofthis emergency organization as it was described in
the documents when the accident at TMI began.
For convenience, the Headquarters and the Region I
components will be dealt with separately. (A moredetailed discussion of the agency's emergency
response planning, entitled "Background on NRC
Planning for Its Response to Emergencies," may befound in Appendix 111.1.)

FIGURE 111-12. Principals in NRC TMI Response, Region Ithis, participation by the NRR and NMSS directors
apparently depends on the nature of the accident.
According to the emergency response documents, the EDO acts as "Director" of the EMT. The
documents, however, fail to indicate the EMT
director's distinct duties or authority. When the TMI
accident began, Gossick interpreted his duties as
EMT director as primarily requiring him to ensurethat proper procedures were followed:

The Headquarters Organization

Primary responsibility for managing a major incident such as the TMI accident rests with senior
NRC staff officials at Headquarters who in an emergency form an Executive Management Team (EMT).
According to the NRC Headquarters Incident
Response Plan, the EMT's functions during an
emergency include the following: 11• On the basis of Commission policy, provide gui-[The director's role was] primarily to see that thestaff was brought physically together in such a way
as to respond in whatever way seemed appropriate
or necessary in an event of this or any other kind,and to make sure that the overall operations of thestaff ... proceeded as we had more or less laid [it]out ... and so forthdance for determining [the] extent of NRC
response to [a] particular incident.
• Make decisions concerning significant NRC actions during [an] incident, e.g., should NRC provide assistance or onsite direction?
• Approve specific NRC directives to the licensee
during incident response.
• Coordinate policy with other agencies andresolve any conflicts between NRC and Federal,
State, or local agencies.

The emergency response documents do not indicate how the members of the EMT should make decisions. During the TMI accident, Gossick's view
was that:

Neither the Headquarters Incident Response Plannor any other emergency response document
discusses what type of "assistance or onsite direction" should be considered by the EMT or when.
These documents also do not discuss important advice that may have to be given to a State, such as
evacuation recommendations. (See Appendix 111.1
for a discussion of the agency's long-standing hesitancy to define clearly its role in an accident vis-avis the licensee and the State.)
According to the pertinent emergency response
documents, the only role of the Commission in an
emergency is to provide "general policy which
determines the overall course of action NRC takes
12
As Commissioner Gilinin response to incidents."
sky has stated: "dealing with emergencies wasdelegated to a staff organization specifically set up
for that purpose." 13 I n his deposition, former Chairman Hendrie offered one possible explanation for
why the EMT is delegated the task of managing a
nuclear emergency:

In essence we were in a normal Staff configurationfrom an organizational standpoint. ... It was primarily the view that the Staff would make recommendations, and to me [sic], if I felt it was appropriate for us to go ahead and carry it out without any
further reference to the Commission, we'd goahead and do it 17

The EMT's principal assistance in an incident
such as occurred at TMI is provided by an "Incident
Response Action Coordination Team" (IRACT). The
IRACT's duties include (1) ensuring that the Commission and other Federal agencies are notified of ani ncident, (2) overseeing the gathering and evaluationof information, (3) identifying problem areas anddeveloping alternative solutions for the EMT, (4)keeping Commissioners and EMT members currently informed concerning the incident, and (5) implementing EMT decisions. 18 For reactor accidents,
NRC Manual Chapter 0502 seems to indicate that
the IRACT will consist of five members, the four division directors of IE and the director of NRR's Division of Operating Reactors. 19 During the TMI accident, however, only Moseley, the Director of IE's
Division of Reactor Operations Inspection, and Stello, the Director of NRR's Division of Operating Reacthemselves
IRACT
tors,
clearly
consideredmembers. 20 The other three IE division directors
as members ofapparently viewed themselves
21
I RACT's support staff.
According to the written instructions, Norman
Moseley, as head of IE's Division of Reactor Operations Inspection, is designated to act as the "Director" of IRACT in reactor accidents. Once again,
however, the emergency response documents do
not indicate what particular responsibilities or au-

I really didn't expect [the Commissioners would]
have much of a role because I anticipated thatevents would probably move fast enough so that
there simply wouldn't be time to involve the Commission which, as a collegial body, is a very slowmoving animal in that kind of discussion."
NRC Manual Chapter 0502 indicates that in every
accident the EMT will consist of the EDO, the directors of IE and NRR, and the Director of the Office of15
Nuclear Material Safety and Safeguards (NMSS).
However, the director of NMSS did not serve on the
EMT and played no significant role during the accident at TMI. Although no document clearly states940

Office of State Program members are expected to
identify State capabilities in an emergency, evaluateState actions, and advise IRACT of "alternatives
available based on
performance levels of State and25
local authorities."
I n "safety incidents" such as at TMI, the NRC
Headquarters Incident Response Plan indicates that
the IRACT support staff's work should be divided(1) "situation
into three functional categories:
evaluation" (evaluation of real or potential causes of
the incident, and determination of whether the situation is under control and consideration of potential
problems), (2) "offsite implications" (evaluation ofreal or potential impact upon public health and safety including consideration of real or potential radioactive releases and meteorology and the potentially affected population), and (3) "NRC field liaison"(communications among Headquarters, the affected
regional office,
NRC personnel at the site, and the26licensee).
The Headquarters plan does not state
how these three functions should be staffed. However, because the "situation evaluation" and "offsite
implications" functions are evaluative, NRC Manual
Chapter 0502 suggests that these functions shouldbe performed by NRR personnel and, because the" NRC field liaison" function constitutes informationgathering work, the chapter suggests that this work
should be performed by IE personnel.
Although the emergency response documents
generally indicate what is to be done and whoshould do it, they do not state clearly how the support staff is to be organized and managed. Does
the support staff divide into three groups based onfunction? If so, who is in charge of each? Does the
I RACT director, who is from IE, directly manage NRR
personnel working on "situation evaluation" or"offsite implications"? Or does he manage only IE
personnel doing "field liaison" work? If they work
separately, who coordinates the work of NRR personnel and IE personnel? These and other organizational questions are left unanswered. During thefirst few days of the TMI accident, the support staff
separated into two general groups-situation
evaluation (generally consisting of reactor speciali sts) and offsite implications (generally consisting ofhealth physicists). Each of the two groups had two
distinct subgroups, one consisting of IE personnel
who primarily gathered information and the otherconsisting of NRR personnel who evaluated information. IE officials supervised only IE personnel and
NRR officials supervised only NRR personnel.

thority are assigned to IRACT's "Director." In his
deposition, Moseley provided a general descriptionof the IRACT director's responsibilities that seemed
no different from the responsibilities of all IRACT
members:

Q: What were your responsibilities as IRACT director?
A: My responsibilities are to have the people assemble to establish communications with the site
to collect information and to have the information reviewed to see if there is any action-to
see first if the licensee is doing those things that
we feel should be done and if not should makerecommendations to EMT for
22 any actions thatshould be taken by the NRC.

According to the emergency response documents, the EMT and the IRACT are to be located in
the Incident Response Center in two adjacentrooms in the East-West Towers building (see Figure111-13). Communication between the two "teams"
should be conducted through an EMT/IRACT Liaison Officer. This single officer is expected toperiodically brief the EMT on the status of an incident and identify both the "principal questions" being pursued and the actions being taken by IRACT.
The EMT questions should be written and delivered
to this liaison officer who maintains a record of thequestions that are submitted. The EMT members
are to "limit their intrusion into the Operations
Room." 23 In providing information to the EMT
through the liaison officer, IRACT is instructed toprovide "evaluation of24
information acquired," not"unevaluated raw data."
The IRACT's assigned responsibilities are performed by an "IRACT Support Staff." In a serious
reactor accident, this support staff should include
personnel from a number of distinct organizational
components including NRR, IE, and the Office ofState Programs. According to NRC Manual Chapter
0502, the work performed by an IRACT support
staff member depends on the organizational component from which he or she is drawn. The NRR
members of the IRACT support staff are to handle
evaluation functions, such as considering the future
course of the incident, possible corrective actions,the feasibility of assistance to the licensee, and theneed for formal intervention by the NRC. The IE
members of the support staff, on the other hand, areresponsible for ensuring that personnel aredispatched to the site to "monitor the licensee's activities," gathering information concerning the incident "to assist in NRC's independent evaluation ofeffects of the incident," and performing "inspection
and investigatory functions in the field required toassure the health and safety of the public and toprovide information requested by EMT or IRACT."The Regional Organization

A licensee must report an incident by notifying
the appropriate IE regional office, not NRC Head94 1

FIGURE 111-13. Arrangement of NRC Incident Response Center in EW Towers

quarters. It was Region I, then, that was responsible
for sending the first team of NRC officials to Three
Mile Island.
The stated "policy" of the Region I Incident
Response Plan includes (1) sending inspectors to
the site "to assure that actions are being taken toprotect people, property, and the environment," (2)coordinating its effort with NRC Headquarters andother Federal agencies and "request[ing] their assistance, advice, and support, as appropriate," andassistance to licensees(3) providing radiological27
and other agencies.
The Region I Plan provides for an incident
response organization under the overall authority
and supervision of the regional director. The organi zation consists principally of a Regional Incident
Response Action Coordination Team (RIRACT) andan onsite inspection team. The RIRACT, headed by
a Region I branch chief, is to receive and evaluate
i nformation from the site and provide continuous information updates to the Headquarters TRACT.
The Region I Plan states that the "primary" function of the onsite inspection team is "to serve in an
i nvestigative role ... in order to gather factual information," although this function may "be subordinated to those of radiological assistance when the nature of the incident is such that health, safety, andproperty"28 damage prevention measures are required.
The plan specifies in an underlined instruction that
Region / personnel at the scene must take care tolimit their activities to that of objective observation,
evaluation and investigation to avoid being directly
involved in directing or ordering actions by thelicensee or other agencies unless the
29licensee's organization significantly breaks down.

According to the plan, the onsite team "will normally consist of four persons" and the plant's project or resident inspector will have supervisory
responsibility for the team. It adds, however, thatmembers of the team "will depend on the nature of
the incident, e.g., the Regional Director may be
Team Leader for Level I [the most serious]
response." 30 Region I's plan lists Donald Haverkamp and William Lazarus as the primary and alternate project inspectors for TMI-2, neither of whom
went to the site on March 28.
Although the Region I plan refers to the need tocoordinate efforts with Headquarters, its language
implies that Region I officials, not Headquarters officials, must make the critical judgments:
Inspectors will be sent to the scene ofi ncidents ... to assure that actions are being taken
to protect people, property, and the environment... 31

943

The Regional Office ... will notify [Headquarters andother Federal agencies] of incidents ... and will request their
32 assistance, advice and support, as appropriate.

[onsite team] members ... determine the magnitudeof the problem and the hazards to the public ... 33

Region I's plan gives no indication that a
Headquarters-based EMT is charged with responsibility for making "majordecisions affecting NRC's
34
response actions."
Moreover, Region I's plan
discusses evaluative work to be performed by regional personnel but does not mention the evaluative functions that are to be performed at Headquarters. Although Region I's plan warns onsite teammembers to "avoid being directly involved in directi ng or ordering actions... unless the licensee's organization significantly breaks down," 35 the plan
does not advise that the EMT at Headquarters must
" make [the] decisions concerning
significant NRC
36
action" such as onsite direction.
2. DESCRIPTION OF NRC EMERGENCYRESPONSE
a. Wednesday, March 28, 1979

The NRC is Notified of the Accident

The Three Mile Island (TMI) accident began at
4:00 a.m. with a loss of condensate and feedwater
flow, which promptly led to a turbine trip and a reactor trip. Metropolitan Edison (Met Ed) was not required to notify the NRC of these particular events.
By 7:00 a.m., however, the reactor core had beendamaged and radioactive materials were being
released. Because of the radioactivity, Met Ed declared a site emergency and notified the State ofPennsylvania and the NRC. A Met Ed employee
called the NRC's Region I office in King of Prussia,
Pennsylvania, at 7:10 a.m. and notified the agency
that a site emergency had been declared. Because
the regional office was closed at that time, the telephone answering service called the home of James
Devlin, the NRC duty officer, and was informed that
Devlin was en route to the office. The answering
service then called the home of James Allan, theRegion I Deputy Director, and discovered that Allan
was also en route to the office. Devlin received asignal on his beeper, but, being near the office, decided to continue and answer the call from the office. NRC officials did not learn of the accident until
the 37NRC Region I switchboard opened at 7:45
a.m.
About 7:50 a.m., the Region I office called theTMI-2 control room. Region I was informed that a"site emergency" had been declared shortly before
7:00 a.m. and a "general emergency" had been declared at 7:24 a.m. "Site emergency" was defined
i n the TMI emergency plan as "the occurrence of ani ncident which could potentially result in an uncontrolled release of radioactivity." "General emergency" meant an "incident which has the potential forserious radiological consequences to the health andsafety of the general public."
About 8:00 a.m., Boyce Grier, Director of Region
I, telephoned John Davis, Acting Director of NRC's
Office of Inspection and Enforcement, at his office in
Bethesda, Md. to notify him of the event. Grier reported that TMI had had a turbine trip, an extraordinary primary system transient, and activation of thesafety injection system. Grier reported that, "Theloss of feedwater resulted in turbine trip which
resulted in reactor trip. What caused the problem
there, I don't know. They got safety injection." 38
The plant had lost pressurizer level and developed abubble in the reactor coolant system; there was also
evidence of failed fuel. High activity was reported in
the secondary system along with a slight increase in
the reactor building pressure.

for TMI-1 and TMI-2, was not sent to the site until
the second day after the accident; he had been assigned to work in the regional incident response
center as a communicator on Wednesday and partof Thursday. William Lazarus, the alternate projecti nspector for TMI-1 and TMI-2, had visited the TMI-2
plant only once during a familiarization visit about ayear and a half earlier. He remained at the Region I
office on Wednesday.
Shortly after the first team left, two more Region I
staff members (Walter Baunack, a reactor operations inspector, and Raymond Smith, an investigation specialist) were dispatched, to the site. Region I
also summoned its mobile laboratory van to Three
Mile Island. This van, which is equipped with air
sampling equipment and radiation measuring instruments to make independent radiological measurements, was at the Millstone Nuclear Plant in Connecticut at the time. Appendix 111.2 describes the
deployment of NRC personnel and their management structure for the first few days of the emergency.
The Region I actions were initiated and carriedout by a Regional Incident Response Action Coordination Team (RIRACT). The Region I director anddeputy director directed the activities. The principal
members of RIRACT were Eldon Brunner, whocoordinated the reactor operations response activities, and George Smith, who coordinated the radiol ogical and environmental activities. Other Region I
staff members were designated to assist RIRACT byhandling communications between the site and NRC
Headquarters in Bethesda, Md. This staff also handled notifications of various State and Federal agencies. Region I contacted the Pennsylvania Bureauof Radiation Protection at 8:50 a.m. Region I also
telephoned State officials in Delaware, New York,New Jersey, Maryland, and Connecticut commenci ng at 10:30 a.m. Calls were also made to the
Department of Energy's Radiological AssistanceTeam at Brookhaven National Laboratory at about
8:45 a.m., the Federal Preparedness Agency Region
II at 11:30 a.m., and the Environmental Protection
Agency Region III at 12:04 p.m.

Region I Initiates Its Emergency Response
Based on information received from Met Ed, Region I designated the accident as a Level I severity
incident (the most severe classification), and began to staff its incident response center and gather
documents describing the TMI-2 plant. An open
telephone line between the TMI-2 control room andthe response center was established to enable NRC
staff members to gather further details on the accident and the status of the plant.
The Region I officials quickly selected an inspection team of five people to go to the site to observeand report what was happening. Members of thisi nitial team were Charles Gallina, an investigation
specialist, who was also an alternate emergency
planning officer; Donald Neely, a radiation specialist;
Karl Plumlee, a radiation specialist; Ronald Nimitz, aradiation specialist; and James Higgins, a reactor
operations inspector. Neely was apparently appointed as the team leader. 40 This team left the regional office for the Three Mile Island plant at about
8:40 a.m.
The Region I Incident Response Plan indicatesthat in a reactor emergency the project inspector
will be sent to the site to act as the team leader.
However, Donald Haverkamp, the project inspector

Headquarters Initiates Its Emergency Response

Beginning about 8:00 a.m., emergency response
measures were initiated at NRC's Headquarters offices. At that time, Joseph Fouchard, Director of the
NRC's Office of Public Affairs, called John Davis,
Acting Director of the NRC's Office of Inspection
and Enforcement (IE), and asked him if he knew944

anything of the happenings at Three Mile Island.
Fouchard had received a call from his Public Affairs
Officer, Karl Abraham, in Region I. This was the firstthat Davis had heard of the accident. A few minutes
later, Davis received a call from Boyce Grier, Director of Region I. Grier explained to Davis what heknew of the accident at that time.
After talking with Grier, Davis directed DudleyThompson, the operations officer for an incident
response, to activate the Headquarters Incident
Response Center. Davis then went to the centerand called Lee Gossick, NRC's Executive Director
for Operations (EDO), at his office to recommend
activation of the agency's Executive Management
Team (EMT). Gossick, designated as the director of
the EMT, agreed and left to go to the center. Davis,
also a member of the EMT, proceeded to notify
Harold Denton, Director, Office of Nuclear Reactor
Regulation (NRR), a third member of the EMT for incidents involving nuclear powerplants. Denton was
not immediately available, so Edson Case, NRR
Deputy Director, went to the center in his place.
Notice of the accident was called to the NRC
Commissioners starting at 8:53 a.m. 41 Joseph Hendrie, the Chairman of the NRC, was away from theoffice that morning. In his absence, Victor Gilinsky,
the Commissioner with highest seniority, assumed
the role of acting chairman. Upon being notified,Commissioner John Ahearne went directly to the
response center as an "observer ... monitoring what
they were doing, trying to understandhow did the42
NRC react in an emergency."
As notifications went out to Commissioners, Dudley Thompson and other designated members of theemergency response staff began to set up the incident response center in accordance with the
Headquarters Incident Response Plan. Moseley organized an Incident Response Action Coordination
Team (IRACT) and a support staff. Moseley called
Victor Stello, Director of the Division of Operating
Reactors, designated as a member of the IRACT in
the event of reactor incidents, to notify him of thei ncident. Moseley told Stello, however, that indications were that the reactor was all right, and that the
problem was probably related to a radiologicalrelease inside the reactor containment system.
Moseley also told Stello that he did not need tocome to the response center, and instead suggested that Stello send someone from his division with43
Accordingly, Stello sent
radiological expertise.
Brian Grimes to work with the IRACT. When Edson
Case arrived at the incident response center, he requested that Stello come to the center immediately.

The responsibility for communicating with outside
agencies was assigned to Bernard Weiss, theOperations Communication Officer. At 9:00 a.m., henotified the Department of Energy (DOE) at the DOE
Emergency Operations Center in Germantown, Md.,
explaining that the NRC might be requesting aerial
surveillance assistance shortly. The NRC's request
for assistance was withheld until 11:00 a.m. The
NRC dispatched a staff member to the DOE Emergency Operations Center in Germantown, shortly
after 9:00 a.m. to act as NRC Headquarters coordinator with DOE. In addition to calling DOE, NRC
Headquarters called the Environmental Protection
Agency at 9:02 a.m.; NRC Congressional OversightCommittees and Pennsylvania Congressmen from
9:10 a.m. to 9:30 a.m.; and the White House Situation Room at 9:15 a.m.
Staff from the NRC Office of State Programs established Headquarters liaison with the Pennsylvania
Bureau of Radiation Protection at 10:45 a.m. This
staff also made calls to officials in surrounding
states to inform them of the accident.
The NRC Incident Response Plan specified thatthe Director of the Division of Operations Inspection(Moseley) would direct the IRACT. The plan also
specified that the Director of the Division of Operating Reactors (Stello) would be a member of the
IRACT in cases of incidents at nuclear reactors. In
actuality, Moseley did not act as Director of IRACT
except during the initial activation and staffing of the
response center. At other times, Moseley and Stello operated as joint leaders for reactor operational
matters. James Sniezek, Director of IE's Division of
Fuel Facility and Materials Safety Inspection, together with Brian Grimes, Assistant Director in NRR's
Division of Operating Reactors, jointly coordinatedradiological issues.
In accordance with the Headquarters Incident
Response
Plan
procedures,
communications
between the IRACT and the EMT were initially handled by a liaison officer. He was supposed to carry
written messages or requests for information backand forth between the two groups. Written communications, however, were only briefly used and nosystematic record was kept of EMT requests for information or of IRACT answers. The procedure forcoordinating communications between the EMT and
IRACT through a liaison officer was quickly found to
be too time consuming and consequently dropped.
EMT members began to communicate directly withi ndividual members of IRACT or its support staff.
Communications developed along organizationalli nes; the NRR member of EMT tended to talk94 5

directly to the NRR support staff, and the IE memberof EMT tended to talk directly with the IE staff
members. Dudley Thompson informed us 44

the TMI-2 control room and the communications linkwith Region I had to be transferred to the TMI-1
control room.
On March 28, IRACT's radiological groupbypassed the field communicator by calling Region I
on a separate line. This resulted in a delay of theregion's response to Headquarters' questions on
operations matters, because the region had only
one line to the site and all questions, both radiological and operational, had to be handled by the TMI
plant operator. This was temporarily resolved when
Stello asked the region to accept only requests for
information that came through the field communicator.
During the morning of March 28, the Headquarters personnel responsible for operations had asecond source of information about the status of thereactor at Three Mile Island. Before Stello left for
the response center, he told his deputy, Darrell
Eisenhut, to gather a staff team to provide additional
technical assistance. Eisenhut did so immediately
and found himself waiting for information from theresponse center. Eager to help, Eisenhut called
Babcock and Wilcox (B&W), the company that had
designed and fabricated the reactor, about 10:00
a.m. to find out what that company knew. Although
B&W's information was incomplete, Eisenhut maintained communications with the company and exchanged information throughout the day.

[T]here was a great deal of difficulty on the part ofboth EMT members and IRACT members of
disconnecting themselves from their organizational
responsibilities and loyalties within the day-to-day
NRC function and reestablishment of relationships
specified in the incident response plan for the
emergency condition.

[T]here was a substantial inclination on the part of
EMT members to obtain information they felt was
crucial to their decisionmaking process, from theirown home staffs, in many cases by physically leavi ng the EMT room and going to collar the individualfrom whom they wanted to obtain the informationand questioning him face to face, rather thantransmitting questions as was proposed in the
response plan in written form through the liaison
member of IRACT to get information back. At thesame time, because of the evolutionary process ofi nformation coming into the center, there was astrong inclination on the part of the IRACT
members, particularly senior IRACT members, totake what bits of information were available at agiven moment in time and feed them directly to arepresentative on EMT, most frequently the
representative with whom they were most familiar;that is, the man who was their boss in day-to-day
activities.

Two groups were organized and located at
separate tables in the IRACT room, one to deal withradiological issues and one to deal with reactor
operations issues. At first, the two groups consisted primarily of IE staff members who gathered information. When NRR members came to the center toassist IRACT, they were stationed in satellite offices
outside of the IRACT areas of the response center.
A field communicator was assigned to maintainan open telephone line to the Region I Incident
Response Center and to transmit all requests andreceive all information from that office. Initially,
Headquarters had only one telephone line open to
the Region I Incident Response Center; through thisli ne, the Headquarters field communicator could ask
the region for information and thereafter received
whatever information the region had been able toobtain. Before the arrival of its onsite team, the region obtained its information by relaying the Headquarters' information requests to a Met Ed plant
operator.
Before 10:00 a.m., the Met Ed operator was located in the TMI-2 control room. Shortly after 10:00
a.m., however, the operator was forced to evacuate

The Region I Team Arrives On Site and Begins Work
Shortly after 10:00 a.m., the initial five-man teamfrom the Region I office arrived at the site and entered the TMI-1 control room. The control room wasalready occupied by Met Ed as a center for gatheri ng radiological data. Neely, who was acting asteam leader, directed Gallina and Nimitz to establish
a command center in the shift supervisor's officeadjoining the control room. The team immediately
called the Region I Incident Response Center to report its arrival at the site and to indicate it had
established contact from a telephone in the TMI-1
shift supervisor's office. Except for an occasionall oss of connection, this telephone link was heldopen to the region response center for days. Appendix 111.3 describes the telephone communications
used by the NRC in the first days of the emergency.
At the TMI-1 control room, the onsite team wasbriefed on the status of the plant by the Met Ed shift
supervisor, James Seelinger, and other Met Ed officials. 5 Team members learned that the atmos-

94 6phere in the TMI-2 control room was contaminatedand entry would require protective face masks.
Neely, who was the lead health physicist, and Higgins, who was the only NRC reactor inspector
present at the time, entered the TMI-2 control roomat about 11:00 a.m. They were the first NRC officials
to enter TMI-2 following the accident. Later they
established a communications link with Region I andremained in TMI-2 until about 7:30 p.m. Neely and
Higgins followed the activities in TMI-2 and relayed
i nformation to other NRC officials.
About the same time Higgins and Neely left to go
i nto the TMI-2 control room, Baunack and Smith arrived from Region I, bringing the total onsite NRC
force to seven. At the request of G. Smith at theRegion I Incident Response Center, one member,
Plumlee, began conducting a radiation survey
around the exterior of the facility. Nimitz, Baunack,R. Smith, and Gallina remained in the area of the
TMI-1 control room and assisted in gathering information requested by the region over the TMI-1 telephone; Gallina took control of the telephone to theregion.
Shortly after 1:00 p.m., airborne radioactivity in
the TMI-1 control room necessitated the use of facemasks by Nimitz and Gallina. Nimitz continued toact as intermediary between Gallina, who was manning the telephone, and the emergency control station in TMI-1 that was receiving survey data andwind speed directions. Baunack and Smith wereunable to obtain face masks and consequently had
to leave the area. They were not able to return until
about 3:00 p.m. at which time they joined Higgins
and Neely in the TMI-2 control room.

TMI-1 line was changed to a two-way connection
between TMI-1 and the regional office. Thereafter,
the TMI-1 line was used for radiological informationand the TMI-2 line was used for operational information.
Throughout Wednesday, Headquarters operations staff members were frustrated by the fact thatthey were talking to people at both the region andthe site who neither had reactor operations background nor understood the questions being asked.
Their direct tie to TMI-1 was manned by Gallina, who
had a radiation protection (health physics) background; Gallina was assisted by Nimitz, who also
had a health physics background.
Communications problems, however, were not attributable only to the NRC officials at the site. The
Headquarters tape transcripts indicate that IRACT
staff members tended to ask their questions inpiecemeal fashion with little attempt to group questions together in a manner that would make it easierfor onsite personnel to gather answers efficiently.
Also, Headquarters did not explain why requested
i nformation was needed or what it was concerned
about. As an onsite recipient of Headquarters' persistent requests for reactor information, Higgins'
perspective was that:

There didn't appear to be any filtering of the questions [by Headquarters] to determine which were
important, which should be asked first, which46
shouldn't be asked; that type of thing.

There were... investigative-type questions, questions on system design, questions for many, many
parameters, a lot of which didn't really pertain to
the particular situation at hand. 47

Higgins felt he could communicate better with Re48
gion I than with Headquarters. He told us

Communications with the Site-A Continuing
Problem

I felt much better able to communicate my findings,
my discussions, and so forth, with what was goingon in the plant with the people that were in the Region, particularly Don Haverkamp, than to people in
Washington.

As the morning passed, Headquarters personnel
became dissatisfied with its indirect telephone linkthrough Region I to the site. As a result, a tie-in
was established between the TMI-1 line and Headquarters at about 12:30 p.m., permitting a three-way
conversation between Region I, the TMI-1 control
room, and Headquarters. However, Headquarters
still lacked any direct communications link to NRC
i nspectors in TMI-2; the onsite information had to bepassed through Region I to Headquarters. At approximately 4:30 p.m., a three-way telephone connection also was established between TMI-2, Headquarters, and the regional office. Concurrently, theReally, the people in Region I were, first of all, familiar with me, and that helped a little bit. Additionally,
they were familiar with the types of things that goon in the plant, in a Control Room, much more sothan the people in Washington. Whereas, when I
discussed these things with them, they knew what I
was talking about.
Beyond that, the people in the Region had somefamiliarity with people, the positions of these people
at Met Ed and the specifics of the Control Roomthat the people in Washington didn't have. They
also appreciated a little more, I think, the types of
R f f

94 7

see is superheating, and if they are superheating,they've got to find a way to get more water in theircore. 50things I was going through on the site and wereable to put a little bit of that into the questions they
asked.

Gilinsky: Well let me understand what you're sayi ng. You're saying that, in fact, the core may not becovered.
Stello: Right. 51

2:00 p.m. to 8:00 p.m.: Growing Concern at
Headquarters

The limited data that NRC offices acquired during
the day indicated continuing problems. First, bits ofi nformation received indicated that the reactor was
not being fully depressurized. Second, additional information began to reflect an exceptional difference
i n the temperatures of the hot and cold legs (thereactor outlet and inlet pipes). By roughly 2:00 p.m.,
staffers from Headquarters were comparing the reported hot leg temperatures with the saturation temperature for the prevailing system pressure. Headquarters concluded that the steam bubbles in thesystem seemed to be in a superheated condition.
The only heat source available for this superheating
was the core itself, suggesting that at least part ofthe core was uncovered and being cooled only bysteam.
Victor Stello, one of the prominent staff members
at the Headquarters Incident Response Center, wasworried about the status of the core. Shortly after
4:00 p.m., with information still too sparse to alleviate his concern, Stello tried to take matters into his
own hands. He "impulsively" took the phone fromthe Headquarters field communicator and spoke
directly to one of the Met Ed shift supervisors in the
TMI-1 control room, Gregory Hitz. Stello told Hitz, "Ifyou really have 550 degrees on that hot leg, it's
clear that you're getting some superheat. If you're
getting superheat, there's a chance the core could
be uncovered." 49 Stello did not order Met Ed to do
anything, but rather relayed his anxiety concerning
core uncovering. Hitz immediately cited the reasons
why the core was already adequately covered, but
agreed to pass on the concern to TMI-2.
Shortly afterward, Stello reported the Hitz
conversation and his concerns to Commissioner Gilinsky, the acting NRC Chairman. This conversationreflects not only Stello's concern about the core but
also Headquarters' poor understanding of the situation at the site:• w

Stello: They're controlling at that pressure for areason I don't understand, and I've never got ananswer that I did understand 52
R

Gilinsky: And are these guys pretty adept technically?
Stello: Vic, it's awful hard to understand. We'retalking through two or three different people at the
moment. We're talking through their generalprincipal-one of the inspectors who is runningfrom one control room to another and then relaying
i nformation back to-through us, and in somecases, through another man. So I don't really have
any way of judging how well equipped they arefrom any given point of view there. I don't know.
Gilinsky: Who is in charge?
53
Stello: I don't know.

The conversation also reflects a firm conviction
by Headquarters that Met Ed, not the NRC, wouldbe "in charge" of correcting the problems with thereactor:,

Stello: And we're trying to understand why they
haven't been willing to open the damn thing-thevalves open and let the thing blow down so they
can really get enough water in there. They've got
bubbles, or whatever they've got to get rid of them.
Gilinsky: Yeah.
Stello: About a half hour or so-or 20 minutes I got
on the phone and explained to them that if they
really have that hot leg temperature as they've indicated, the only plausible explanation that I could

Gilinsky: Well is there anything we ought to doabout that beyond having talked with this guy?
Stello: The only thing I can think of doing is to use
our minds and understanding and tell them what we
think based on the facts we hear, and they must
make the judgment. We cannot make the judgment
here, because we're relying on information that'sfrom too many different channels. I don't haveenough information myself to decide what I wouldde [sic]. I can only react to54
the facts and raisequestion for them to consider.
ww

Gilinsky: We've got to be careful that, you know,
they don't start asking us what to do and then ....
Stello: No. They're in charge, and we can onlyoffer something that we thought of, but they are absolutely in charge. There can't be any question
about that. And we don't want any confusion inanybody's mind, especially in their mind. I mean
they are on top of the situation, and we're at theother end of the telephone.
55
Gilinsky: That's right.

Stello: We'll make it very clear to them that the decisions that are being made are theirs, and56that the
only thing we're doing is asking questions.
f f f

The single 4:00 p.m. conversation between Stelloand Hitz appears to be the only contact between
NRC Headquarters and Met Ed. In spite of the frustrating lack of information and Stello's concerns
about core cooling, Headquarters officials did not
94 8

call the plant management directly. According to
Stello, "It didn't occur to me to talk to anyone in the
management of the plant beyond the individual I
talked to." 57
Nor, it appears, did Headquarters discuss Stello's
concern about core cooling with one of the onsite
reactor specialists from Region I. Higgins, for example, was in the TMI-2 control room throughout theafternoon, but was never informed of this problem.
The following statements were made by Higgins in
response to questions asked by the Special Inquiry
Group: 58

need to send a post-recovery team to the site.
Existing license conditions (technical specifications)and procedures were no longer applicable to theplant in its then-existing accident condition. Realizi ng that new procedures would be needed in orderto place the plant in a cold shutdown condition,
Headquarters sent a seven-man team of licensing
engineers to the site, headed by Richard Vollmer of
NRR, presumably to review and approve the revised
procedures that the licensee would be preparing.
As Vollmer put it "Well [our mission] was sort ofopen ... we had to have a first hand knowledge ofwhat was going on and also theye1 wanted us toreconstruct ... what had happened."

0: Do you recall any questions or suggestions
coming in from Region I or from Bethesda relating to saturation conditions or relating to thecore being uncovered?
A: No.
Q: Do you recall anybody over the phone saying,
Hey, we think there's a core coverage problem?
A: Definitely not.
Q: You don't recall that?
A: Definitely not, because there were discussions
among the caucuses that went on as to Gary
Miller saying the type of Thing: Does anyone
here feel we're not providing adequate corecooling or adequate core coverage? I didn't feelat that time there was a problem. I didn't havean indication the people on the other end of thephone in Washington felt that either.
I guess I can add here some things I foundout afterwards?
Q: Sure.
A: Afterwards, that Mr. Stello called the Unit 1 Control Room and talked to an operator there sometime in the afternoon and asked that operator topass on to their management the NRC's concerns about core coverage, which if that happened, it just never did get to the caucuses,
never did get to the right people, and in fact was
really not the right way to get it to the management because, first, coming from Mr. Stello atthat point, that's certainly a significant comment
because that represents some type of NRC
caucus, I would think, some type of NRC consensus that had that feeling.
If I had heard that, I would have certainly taken some steps to find out why they felt that andtried to communicate that to Met Ed.

2:00 p.m. to 8:00 p.m.: Activities at Region I and theSite

As the day progressed, it became clear that additional Region I officials would be needed. At about
1:00 p.m., William Raymond, a reactor operations inspector, was dispatched to the site to relieve either
Baunack or Higgins, but he did not begin working
until midnight. Raymond, having served as a startup
engineer for Babcock and Wilcox at TMI-1, was thefirst reactor operations inspector with substantial
previous experience at Three Mile Island to arrive
on site.
At 4:00 p.m., Grier received a call from Norman
Moseley at Headquarters who informed him that
Headquarters
was not getting much information
62
from the site.
Grier does not recall what he did in
response to the complaint, 63 but a three-way telephone connection was established at 4:34 p.m.
between the TMI-2 control room, Region I, andHeadquarters.
Moreover, about the same time, Grier directedRichard Keimig, a reactor projects section chief who
knew something about the TMI-2 reactor, to go to
the site as the senior onsite NRC official to better
coordinate the NRC onsite effort. Keimig did not arrive at the site until some 5 hours later.
Shortly after 7:30 p.m., the NRC's mobile laboratory, recalled earlier in the day from the Millstone
Plant in Connecticut, arrived at the plant with John
(Phil) Stohr and James Kottan.
During this period, members of the onsite team
were trying to obtain and evaluate reactor information while keeping Headquarters posted. The onsiteteam seemed to be fighting a losing battle as Higgins later testified:

Higgins testified that he believed Headquarters
could have communicated with him in the TMI-2
control room on Wednesday most of the time during59
No guidance was provided; only
the afternoon.
questions were asked by Headquarters.
Midafternoon: Headquarters Decides to Send Its
Own Team from Headquarters

I think if we had a dozen people there getting
answers to the questions we couldn't have gotten
them all and still kept up with the on-going developi ng situation in the Control Room. So, I tried to give

While concern mounted about the reactor core,
the senior NRC staff at Headquarters discussed the
94 9

my first priority to keeping track of the situation as
it was developing in the Control Room, keeping
track of management plans for where they weregoing to go from there, and providing that information back to the region and Washington and picking
up as many of the questions that I could and theones that appeared to be more important to me
and provided answers to those back to the reg~I n his testimony Higgins also noted:

65

I really got no direction as to where to put my priorities from anyone else; so, I set my own as to what I
felt was most important.
A lot of time was spent in participating in thecaucuses that were held in the Shift Supervisor's
office with the plant management there. At the time
there were discussions how they were going, froma systems standpoint, go from where they were.

and Gallina gave the briefing alone. These two individuals became the principal spokesmen for the
NRC to State officials that day and continued in thatrole through most of the following day.
At about the same time these NRC officials left
the site to brief the Lieutenant Governor and Governor, Met Ed was trying to repressurize the reactor
and restore reactor coolant pump circulation. Improvement was achieved by 8:00 p.m. and the
problem seemed to be under control. NRC officials
appear to have played no role in Met Ed's decision
to repressurize, but Headquarters personnel were
nonetheless pleased. Lee Gossick in a conversation with Commissioner Kennedy late Wednesdaynight said:[E]arlier this evening, oh, in the neighborhood of
9:00 o'clock, things took a turn for the better as far
as the reactor is concerned... it was apparent that
we still had an air lock or steam binding.... They finally bumped it with the main recirculation pumps
and got it cleared up, and now they're coming
down in orderly fashion. We're a bit ways yet froma point where we can go on the heat removal system, but we are fairly relaxed now about the reactor itse!L 6s

I was active but I really didn't have too much input.
Whenever we had an input or comment, they werewilling to listen to us. However, my level of experience with the plant was limited compared to what
the plant operators had, and therefore as they got
i nvolved in a lot of technical-type discussions on
systems and equipment, clearly their knowledge
and their experience on how to handle particularthings were better than ours. So, therefore, they
carried the majority of the discussion for these reasons, and also with the Met Ed and the B&W people.

As Stello would later say:

I had a sense of confidence that the core was being
cooled and the worst of the accident was behind us
when that pump was started. And I think that there
was a general sense of a relaxed attitude at thatpoint, that people felt that that was really the major
milestone, getting that pump on and getting water
circulating through the system.
So there was a sense of relief and understanding what happened and know where to go fromthere. There was not a feeling of a great deal ofpressure at that point. It was letting things come as
they did. No feeling of real urgency that I recall following sometime Wednesday night or Thursday.
That it looks like, you know, the biggest part of the
problem is behind us. We now need to understand67
what we have before you can take the next step.

I feel ff I had known the plant very thoroughly I
would have been able to make a much more significant contribution than I did, yes, both to discussions or to helping to correct the on-going situationi n the plant but also to be able to provide muchbetter information, much better evaluations back to
the Region and to Washington.
Actually, throughout the first day I was on alearning process myself to update myself as to exactly what equipment they had, what parameters
were measured where, what the significance of
those parameters were.
But by the end of the day I was able to answer a
lot of the questions over the phones by going out
and getting the information myself directly from thepanels. When I first arrived I wasn't able to do that.
Evening Activities at Headquarters and On SiteThe Worst Is Believed OverI n the early evening, Region I officials received
word that State officials wanted to be briefed about
the situation at Three Mile Island. Higgins, Neely,
and Gallina were directed by Region I to go
Wednesday evening to the State capitol (Harrisburg)to inform the Lieutenant Governor and Governor.
Neely and Higgins left the TMI-2 control room at
about 7:30 p.m. and were joined by Gallina. They
were to go to the observation center and from there
be driven in a State Police car to the Capitol. However, Neely's trousers were found to be contaminated, forcing him to remain. Consequently, Higgins

950

The evening passed in a general atmosphere of
relief. Communications were greatly improved, theplant appeared to be in a stabilized cooling mode,and responsible local officials were being briefed by
NRC and other personnel on site. Shortly after midnight, NRC issued a press release stating that theplant was cooling, but a high level of radiation existed in the reactor building and some measurable radioactivity releases had occurred off site.
By the end of the day, a total of 11 NRC officials,
all from Region I, had been sent to the site.
NRC Contacts with Federal Agencies and Congress

From the initial reporting of the accident, a great
deal of interest was expressed by other Federal
agencies, congressional oversight committees andI n deposition, Eisenhut was asked why he did not
specifically mention superheating. He responded byreferring to the above statement and said:

congressmen whose districts included or surrounded Three Mile Island. For several days following theaccident, the NRC received many calls, most ofwhich were handled by designated NRC senior staff
members who devoted practically full time to this effort. Some calls, however, were handled by the top
NRC management staff who were directing NRC's
emergency response activities. In all, considerable
ti me and effort was involved in keeping Federal
agencies and congressional offices informed
throughout the emergency.
In late afternoon, NRC Headquarters was notifiedof the desire of the Subcommittee on Energy andthe Environment of the House Committee on Interior
and Insular Affairs to be briefed the next day. The
NRC staff began preparing the briefing Wednesdaynight, and selected the senior staff members who
would remain at the response center through thenight and those who would give the briefings thenext day. Darrell Eisenhut, Stello's deputy, and Edward Jordan, Moseley's assistant director, were
designated to be the principal spokesmen at thebriefings. Lee Gossick, the EMT Director, andChairman Joseph Hendrie would accompany them.

Well, I think it's there. I think where you get steam
in a PWR is from superheat. Steam is not present
in a PWR. It's clearly pointed out this is a PWR.
That's why I read the next sentence. It's importantto say that the next sentence points it out: "Thesystem was not flowing by natural circulation. Because of that, the licensee elected to go on a pathof bringing the system up solid, heating it up andbringing it back to pressure, to try to either collapse
or do away with any bubbles in the system." 73

What was clear to Eisenhut (an engineer) may
not have been clear to the Commission. Regarding
possible core damage, Eisenhut stated:
We can't really say too much about the core, except we can make one inference from the activity.
The activity levels that we have seen inside thecontainment would infer that we have had fuelfailure. To the degree of fuel failure, it's just unclear. One radiation monitoring instrument locatedat the operating deck level indicated a radiation level of 10 roentgens per hour. Another monitor in thedome of this building indicated a level of several
thousand roentgens per
74 hour, but was suspected of
not reading correctly.

With regard to possible health effects, Moseley's
assistant director, Edward Jordan, reported that:b. Thursday, March 29, 1979
Activities at Headquarters-Briefing and FactGathering[ T]heoff-sitemeasurementsofradioactivity ... indicated that there is no immediate
threat to health and safety .... We believe that theoff-site airborne radioactivity 75has resulted inminimal exposures to the public.

At 9:55 a.m. five staff members, including EMT
members Gossick and Davis, briefed the assembled
Commission in their Washington office. Stello's
deputy director, Darrell Eisenhut, explained that the"sequence of events that occurred early yesterdaymorning is a little bit sketchy at this time" 68 and thei nformation Headquarters had "is very prelimi nary". 69 He indicated, however, that the plant had"somewhat stabilized" 70 and the "primary goal rightnow is to get the plant down to a temperature configuration where it can switch
to the RHR [decay heat71
removal system] mode."
The briefing to the Commission did not specifically refer to Victor Stello's concern the day before
that the existence of superheated steam conditions
indicated that the core had been uncovered; thishad been previously expressed to Commissioner
Gilinsky. Eisenhut, when asked by Hendrie aboutl arge differences in hot- and cold-leg temperatures,
said:

Yes. We had some quite large hot-leg cold-leg
temperature differentials yesterday of maybe 2- to
300 degrees F.
Our only belief may be that it was associatedwith some steam binding, perhaps maybe notsteam as much as a bubble somewhere in the system 72

Staff members informed the Commission of a"recovery operation" plan using an onsite group
under Richard Vollmer. Lee Gossick reported that:[T]he team up there at present, of course, are the
I&E people that are ... following the events andcommunicating back with us. Mr. Vollmer's group,
when they will arrive, will literally assume theresponsibility for seeing that the state of the plant is
kept in a safe condition; any changes to tech specs
and all the things that have to be done to assure
the continued safety of everything.76

Eisenhut went on to say:

By that we don't mean taking the primary leadaway from the licensee. Another way may be to
say that when the incident center closes down at
the point the event is in a stable mode, Dick
Vollmer's team takes over as sort of incident centeron the site.76

In response to a question concerning the relationship of NRC with the State and other Federal
agencies, Gossick reported:

95 1

My impression is that it has gone quite well. I thinkearly on there may have been some misunderstanding as to what was actually going on. But

certainly, with all of the other federal agencies here
i t went very smoothly ... [Governor Thornburgh]seemed to be quite satisfied. 77

a growing feeling that -of lack of confidence in thelicensee's performance.

Preliminary results of a reactor coolant sample,
taken Thursday afternoon, further heightened Headquarters' concern. Headquarters had been asking
for a sample since Wednesday, but high levels ofradiation in the auxiliary building had prevented Met
Ed from obtaining the sample earlier. The reported
radiation dose rate (1000 R/h from a 100 ml sample)
brought new attention to the state of the reactor
coolant and the reactor core. Stello testified that
this "was starting to suggest that you had an awful
lot of fission products in there beyond the kind offission product inventory you might suggest from80
just a fuel rod failure."Discussions through theevening included the estimate that 10% of the core'sradioactive inventory had been released into thecoolant.
By late evening, Headquarters had been notified
that radioactive gas releases could be expected tocontinue. Furthermore, radiation readings outside
the plant reflected that gas releases originated fromthe reactor coolant letdown and makeup system
and not from spilled water on the auxiliary building
floor as initially assumed.
Earlier Thursday afternoon, Chairman Hendrie
and NRC senior officials briefed the House Committee on Interior and Insular Affairs, Subcommittee on
Energy and the Environment. In the briefing,
Eisenhut indicated he had "every reason to believethat the plant is in a stable condition and that thesystems are performing in a way we think is well81
understood at this time."
The NRC staff indicated,
however, that assessments were still being madeconcerning the seriousness of the accident andpossible steps necessary to bring the reactor to acold shutdown. When asked whether he was maki ng a "best-case" presentation, Hendrie indicated he
was not:

While the Commissioners received their briefing,
Headquarters officials continued to gather and assess the little information available. Staff members
seemed satisfied that the situation was stabilized
but remained concerned as to its seriousness.
78
Roger Mattson recalls:
I recall receiving information that the core had been
partially uncovered for several periods of time inthe course of Wednesday. I recall receiving information that there were indications of high radioactivity in a number of places in the plant. I recall bei ng told that the licensee's estimate was that the radiation could be explained by an iodine spike or acrud burst, which would be indications of much lesssevere damage than we came to recognize [later]on Thursday and Friday.
I recall considerable dissatisfaction with that
opinion on the part of the staff in general. That is, atendency to believe that it was more serious thanan iodine spike or a crud burst, but also a general
feeling of frustration on the part of the technicalpeople who had been involved at the time I was
speaking to them, that they had very incomplete
and oftentimes conflicting information as to what
was going on at Three Mile Island.

And again there was skepticism-I recall a general
feeling of skepticism on the part of the people I
talked to in Mr. Eisenhut's office, that that explanation did not comport with all the information that
was available from the site, that other information
available from the site indicated much more damagi ng consequences to the fuel.

As the day progressed, the flow of incoming information to Headquarters improved, but did nothing
to allay the staff's concerns. By this time, readingsof the core exit thermocouples were conducted regularly and still showed superheated steam temperatures at the top of the core. Moreover, by later
Thursday afternoon, Headquarters realized that Met
Ed was not going into the decay heat removal system79
phase of cooldown. Edson Case would later recall:

What I was trying to do was to outline for you what
seemed to me to be the most likely situation in viewof the limited information we have on the nature of
the fission product releases and the general magnitude. The releases that we have seen, the fact that
it is limited, apparently, to noble gases, would suggest that there was not any melting. The magnitude suggests that perhaps about one percent of
the fuel in the core might have been involved in thecladding cracks.
So I do not know that I am trying to give you themost favorable picture; I am trying to give you theone that seems the most consistent with the otherpieces of evidence we have at hand 82

I think there was, at least on my part, a growing
feeling on Thursday that things were getting worse,that we had a rather unusual change to a very
unusual situation on our hands. I don't recall any
specific thinking on that point, but I also undoubtedly had a warm feeling knowing Vollmer was on theway and would be there shortly.

I think I perceived [the situation] improved in termsof factual information for sure, because we started
getting all thermals and were plotting on those.
As far as confidence in the quality of information, getting significant information from the licensee, I think it was deteriorating during Thursday. In
other words, I think there was, at least on my part,The congressional briefing, like the Commission
briefing, did not cover the issue concerning superheated steam conditions and possible core uncovering.
952

The Need to Dump Industrial Waste-Coordination
Problems

At about 8:30 p.m., Joseph Fouchard and Case
informed Hendrie that the releases were within the
Met Ed technical specification limits and that theState had earlier agreed it would not object as longas the NRC approved. Hendrie told Case that if the
EMT had indicated it was "aboard on it" when talking with him earlier (5:30 p.m.) "that would have settled it. It just didn't sound that way when I talked toyou. -84 A decision was made to tell the Governor's
staff that NRC believed it permissible to release thewater and to await the Governor's concurrence before advising Met Ed. Eventually the plant received
permission to resume release of the wastewater at
12:15 a.m. Friday morning.

Early Wednesday morning, Met Ed discontinued
dumping industrial wastewater from toilets, showers,
and drains into the Susquehanna River. The wastewater contained concentrations of radioactivity well
below the NRC disposal limits.
By Thursday afternoon, some 400 000 gallons ofwater had been accumulated. At this time, Met Ed
requested the permission of both the NRC andState officials to release the wastewater. Both
State officials and NRC officials on site and in Region
I consented provided that the contained radioactivity
was below the applicable NRC limits. Dumping had
already commenced when the NRC Commissioners
were informed of it at 5:30 p.m. As a result, Chairman Hendrie called the NRC Incident Response
Center and decided that the EMT and NRC staff had
not received adequate information on the subject:

Evening at Headquarters-Identification of a
Hydrogen Bubble Concern

By late Thursday evening, Roger Mattson, Thomas Novak, and other analysts at Headquarters hadenough information to conclude that there was alarge noncondensible bubble in the reactor coolant
system. Efforts began to determine how much ofthis bubble was hydrogen and how to remove thebubble safely. At about 8:30 p.m., analysts at
Headquarters called and requested Merrill (Mat)
Taylor to estimate the possible radiolytic generation
rate of hydrogen if the plant was taken to low pressure. Taylor called back about 10:00 p.m. with arough estimate that 1 to 2 standard cubic feet of hydrogen would be generated per hour if the pressureof the system was near atmospheric pressure (Appendix 111. 4). Neither the question nor the answer
dealt with the possibility of the system staying athigh pressure with a bubble maintaining a hydrogen
overpressure on the coolant.

Hendrie: What's going on with this dump down atThree Mile into the Susquehanna?

I just got a report they'd released 400000 gallons
of slightly contaminated water into the river.
I thought they weren't going to do things like thatwithout letting us know.

Edson Case: Well, they let-as I understand it,they let us know they were dumping the-they
maintained, I gather, that it was in the licensed limits.

Hendrie: Now, it would be-ff you-if Three Mile
were operating normally then the licensee mightfind it within his license to go ahead and makethis release, that would be all right. In the circumstances, why the impression everybody will
have is that he's dumping the contaminated water
into the river.
Case: Bad PR, agreed.

Later Thursday night and into Friday morning, the
NRC Headquarters group conversed with B&W personnel at Lynchburg, and discussed holding or
depressurizing
thereactorcoolant system.
Although no NRC notes or recollections confirm it,
those of D. Nitti of B&W indicate that he told NRC
that the generation of hydrogen and oxygen by radiolysis would not be a problem provided the system stayed at pressure with a hydrogen overpressure, which it apparently had.

Why don't we just call them up right now and tellthem to stop if he hasn't stopped it?
Hendrie: I think something like that would be
use be more useful if we had started a little earlier....

At the EMT's direction, Morris Howard, who wasacting as a member of IRACT at the time, called theregional office and told George Smith that thereleases should be stopped. Smith had been one ofthe people who previously indicated that the dumping would be permissible if within the existing NRC
li mitations. Smith relayed to Headquarters that thereleases were within NRC technical specification
limits and warned that if not dumped, overflow of thestorage tank onto the turbine building floor could
occur. Nonetheless, as directed, Smith terminatedreleases '/2 hour later.

Activities at the Site-As at Headquarters, theEmphasis Is on Briefing and Fact-Gathering

The NRC significantly increased the quantity of
its onsite response force throughout Thursday. Region I dispatched additional inspectors while
Vollmer's seven-man team traveled to Three Mile Isl and from Headquarters. By Thursday's end, there
95 3

were 28 officials on site, 7 from Headquarters(Vollmer's team) and 21 from Region I.
Most of the day was spent gathering facts concerning the reactor and radiological release data.
Operational data was relayed to both NRC Headquarters and Region I by way of a three-way phone
connection with the TMI-2 control room. Radiological data was forwarded to Region I from the TMI-1
control room and the data was subsequently relayed to Headquarters. Included in the radiological
data sent to the region were two reports of gaseous
releases measured above the stack by helicopter.
These readings were far higher than other readings
reported on Thursday and equalled or exceeded areading on Friday that eventually triggered a frenzyof action at Headquarters. The first reading on
Thursday at 9:40 a.m. was 1200 mR/h (betagamma) and 120 mR/h (gamma); 85 the second
reading at 2:10 p.m. showed 3000 mR/h (betagamma) and 400 mR/h (gamma). 86 Headquarters
tape transcripts reflect that the morning reading wastransmitted to the Headquarters Incident Response
Center, and some circumstantial evidence indicatesthat the afternoon reading also was transmitted to
Headquarters. However, the IRACT support staff
members responsible for radiological matters appear to have no recollection of either hearing or
seeing these Thursday readings.

AE operation, to see that they were satisfied thatboth the extent of the I&E surveys were adequate
and that in their view the releases were not something that should be alarming from a public point ofview, public safety, we should think about evacuation or anything like that.
Secondly, I asked the systems people to try to
get the information they could to start forming a
scenario of what had happened to evaluate thesystems that could be useful in keeping the reactor
conditions in a stable condition in the next-then I
think we were talking about the next few hours or
few days. 87
At the site, Vollmer discovered firsthand the difficulty in communicating with NRC Headquarters:

Communications were very bad. At the observation
center [across the river from the plant] there werea few phone lines. Even when the phone was available, some of the circuits were often busy.
I can recall actually crawling under one of thetables to get away from the noise and the people
and so on and actually trying to hold a phone
conversation back to Bethesda. In one case I had
to drive back to Middletown to call back becauseeven the pay phone happened to be out of order at
the response center, and there weren't any phones
generally available. There were a few homesaround there but I didn't feel I would burst in on
people and use that. So I drove back to Middletown to make some phone calls.
The communications really were all right after
we got back to the motel.88

James Higgins, the reactor inspector who had
spent most of Wednesday in the TMI-2 control
room, did not go directly to the plant early Thursday
morning. Instead, he was instructed to wait at the
motel for the arrival of Vollmer and his team. Upon
their arrival, Higgins escorted them to the site andarrived there around noon. After he and Richard
Keimig briefed Vollmer's team, Higgins returned to
the TMI-2 control room. Less than an hour later,
Higgins and Gallina were dispatched to rebrief theGovernor and Lieutenant Governor. When Higgins
and Gallina left the control room, they were notaware of the very high level of radioactivity in thereactor coolant system. Higgins learned of thehighly radioactive sample after the Governor's press
conference. After hearing about this sample, hecalled the Governor's office immediately to report
this information.

Vollmer felt he solved the communication problems after he returned to his motel Thursday eveni ng and set up a "meeting room" for the team.88
Nonetheless, Headquarters EMT member Harold
Denton would later say:My recollection is that Mr. Vollmer's staff fell into an
Einsteinian black hole, and communications wereso poor that there was either the lack of goodcommunication links with the site, or either Dick
was busy doing things and didn't have time to call,but there sure was very little back from Vollmerfor89
the 24 hours that he may have been there.

Onsite officials spent a substantial amount of timeattending to congressional delegations. Senator
Gary Hart, the Chairman of the Senate Committee
on Environmental and Public Works, Subcommittee
on Nuclear Regulation, made a personal visit to thereactor site Thursday for a firsthand briefing concerning the accident and a tour of the reactor. Senator Hart was accompanied by several other
Congressmen, including Senator John Heinz (R-Pa.)and Representative Allen Ertel (D-Pa.). Later thatsame afternoon, another congressional delegation,
which included Senator Richard Schweiker (R-Pa.),
Representative William Goodling ( R-Pa.), andRepresentative Robert Walker (R-Pa.), visited the

Although the Vollmer team's general mission was
to establish better communications between the site
and the NRC staff at Headquarters, as well as better
understand what had occurred the day before, instructions to the team were imprecise. With regard
to his team activities on Thursday, Vollmer testified:
I made assignments to the people in my group, as I
said, with the radiological people to follow with the954site for a briefing and tour. The visits by the twocongressional delegations came at busy times forboth the Met Ed and NRC staffs; nonetheless, all
was put aside until the briefings and tours were finished. Richard Keimig, the top IE official on site,
spent most of the day preparing for the delegations
and escorting them around. Vollmer also spent timetaking part in these briefings.
The NRC's Evacuation Discussions with the State

During Thursday, officials of the State ofPennsylvania received evacuation recommendations
from private citizens and also, it appears, from Anthony Robbins, Director of the National Institute ofOccupational Safety and Health of HEW. 90 Yet,
there seems to have been only two fairly brief exchanges on this subject between officials of theState and the NRC. Thursday morning, Commissioner Gilinsky spoke to Lt. Gov. Scranton who
asked whether children in nearby Goldsboro should
stay indoors. Rather than offer his own view, Gilinsky offered to have an NRC staff member provide
advice; shortly thereafter Harold Denton called Mark
Knouse of Scranton's staff for that purpose. Denton told Knouse that there was fuel cladding damage but not core or fuel melting. He ascribed thegaseous releases to the spilled water in the auxiliarybuilding and said it was mostly 1 33Xe gas. When
asked about taking precautions to protect school
children from iodine activity, Denton said, "I don't
think iodine should be the, the concern." Denton
went on to address the issue of evacuating older
people and the sick, saying "you wouldn't want tocreate any stress in the elderly," when these radiation levels are "a factor of a thousand or so below
the EPA evacuation guidelines." 91 Denton had nofurther conversations with State officials about
evacuation or other protective action during Thursday, nor have we found any indication that the
I RACT or IRACT support staff gave serious attention
to this subject before Friday morning.
At the Thursday meeting with the Governor, there
was extensive discussion of whether to carry out anevacuation of people from areas surrounding thesite. Among those present were Higgins and Karl
Abraham, the NRC Public Affairs Officer from Region I who was also serving as a liaison with theGovernor's office. Abraham suggested that State
officials consider the greater sensitivity of certain
people, such as pregnant women, to radiation. We
could find no information to indicate that Abraham
had discussed this view with NRC Headquarters either before or after he offered this suggestion to theGovernor.
95 5

c. Friday, March 30, 1979
Friday Morning Activities at Headquarters-A Callfor Evacuation

The plant had been operating since 8:00 p.m.
Wednesday with only one reactor coolant pumpproviding core cooling flow. The Met Ed staff was
carefully watching the core exit thermocouples.
Many were still showing high readings, but the temperatures were falling. The plant was slowly cooling
down. The plant staff knew that a large bubble ofnoncondensible gas, perhaps 1000 cubic feet, wastrapped in the reactor coolant system. Operators
were using the letdown and makeup system to draw
reactor coolant and gas out of the system. Once
depressurized, the reactor coolant, like open champagne, would free the excess noncondensible gas.
The gas relieved was highly radioactive, and theplant staff was trying to hold it in the waste gas
storage tanks. None of these operations wasproceeding normally, and there was a leak from thepiping used to transfer the gas to the waste gas
storage tanks.
Thus, there were occasional
releases of radioactive gas, or burps, to the atmosphere.
Headquarters was receiving increasingly bad
news on Thursday night and early Friday morning.
There were reports of very high reactor coolant activity, confirmation that the reactor core had been
uncovered, high reactor core thermocouple readi ngs, large bubbles of gas in the system, and occasional releases of radioactive gas that were notcompletely understood. Beginning sometime Thursday, Lake Barrett, an NRR staff member helping the
IRACT to evaluate offsite consequences, had become troubled about the potential
for increased ra92
dioactivity releases to the air:
We were concerned about the gas that would begoing to these tanks ... we knew... that the gas
entering the waste gas decay tanks was highly radioactive and we were concerned that these tanks
had enough capacity to keep receiving this gas,that we would not have this gas being released
directly to the environment.
We could never seem to get any firm informationon the status of the waste gas decay tanks.
The EMT Hurriedly Considers Evacuation

About 9:00 a.m. the highest level NRC staff at
Headquarters began to gather at the incident
response center. Harold Denton had just returned
from an appearance on the Today show and wasage from direct opening in the containment .... I
think I had had mounting concern about the statusof the core from these inputs, and then the 1250
[sic], when that report came in, sort of was the final
straw that says here's the beginning... and for all I
knew the next hour would be 2000 mR over theplant. 98

receiving a concentrated briefing when an unfortunate series of events occurred.
According to a Region I message form, a report93
at 8:45 a.m. from James Higgins at the site read:IS]eal return to makeup tank is causing excessive
offgas in makeup tank which in turn is directed towaste gas tanks which are full. Waste tank being
dumped to STACK which is causing a more considerable release rate. Civil Defense and State arebeing notified by licensee.

I n his deposition, Higgins stated that he remembered passing on information regarding "different
aspects of [the] release path in the makeup systemand the vent system" to Region I, but it is unclear
whether the Region I message form accurately re94
The
flects a report sent by Higgins that morning.
substance of this message apparently was relayed
to Barrett at Headquarters shortly before 9:00
5 Barrett considered the message grave. Bara.m.
rett had previously estimated that a release of 1 curie per second in the gas could produce an offsite
dose rate of 20 mR/h. He concluded that, with thewaste gas tanks full, there was no additional
storage space for the gas being let down from thereactor coolant system to the makeup tank, so thegas would be released to the atmosphere throughrelief valves at the rate at which it was being let
down. Barrett calculated that the release could be
about 60 curies per second, giving an offsite dose
rate of 1200 mR/h.
Barrett was just reporting his rough calculations
to people assembled in the EMT room when a report was received that there had been "an uncontrolled release of airborne activity from a release
point in one of the cooling towers" measuring 1200
mR/h. 96 The report came at 9:09 a.m. from Karl
Abraham, the Region I Public Affairs Officer, who
was at the Governor's office in Harrisburg. It was
clearly a second-hand report. Abraham had beenasked by the Governor's staff to verify it. Abrahamreported that if the measurement was accurate, thePennsylvania Emergency Management Agency
would immediately start preparing for evacuation.
The designated members of the EMT were Gossick, Denton, and John Davis. Edson Case and others were present in the EMT room. With the reported measurement, those assembled fell into quick
debate.
As Denton remembers it, the reported measurement was over the plant, and thus the expected
dose rate at the nearest offsite boundary would be
100 to 200 mR/h.97 But this amount was enoughfor Denton to conclude that evacuation was necessary. As Denton later explained it:

Case had a different understanding about the report. He believed the 1200-mR/h measurement was
not an onsite reading at all; it was an offsite reading,
one that confirmed Barrett's rough calculations. 99
Case also concluded that evacuation was necessary. With a 1200-mR/h offsite reading, hereasoned, "[Y]ou're in the range or getting close to
the range where100
EPA [Protective Action Guidelines]
says evacuate."
Neither Case nor Denton took steps to confirm
the accuracy of the reported reading, which each101
understood differently. According to Case:I guess I assumed, rightly or wrongly, that getting
the 1200 mR report from IRACT must have comefrom the Licensee.

Q: Why wasn't there a decision made to call thestate simply to find out what they knew about
the situation?
A: Because I never in my wildest dreams would
think they had better information than we did.
f f f

0: And finally, what about a communication to Mr.
Vollmer? I know you had indicated that was one
person you knew [at the site] and felt comfortable being able to call. Was there an effort
made to call him?
A: No.
. ff
A: I guess it's fair to say that I also felt that taking
much time at confirming was not the right thing
to do, because the longer you took, the more-if
i ndeed it were true-you were resulting in exposures to people while you were verifying it.
f R R

Like Case, Denton did not try to confirm the critical report. Denton testified:

I felt sort of the obligation to make that recommendation without further checking or attempting toverify it, and sort of assumed that it had been verified accuratey 1 02

Having determined that an evacuation wasnecessary, Denton felt that the Commissioners
should be called "to get their concurrence"-not because this was required, but
because that was "the103
But when initial efforts
way the system worked."
to get the Commissioners failed, Denton decided totake action. Apparently unknown to both EMT
Director Gossick, who was still trying to reach the04
and EMT member
Commissioners
by telephone 1
105
who was in and out of the EMT room,
Davis,
Denton told Harold Collins from the Office of State
Programs to advise State officials immediately of the[I]t was this uncertainty about what will be the nexthour release, and it was just the beginning of leak95 6

EMT's evacuation recommendations.
Denton gave
106
Collins no specific instructions.
I nstead, he relied
upon Mr. Collins' judgment.
Why didn't Denton call State officials himself?
Denton would later explain:
I l ooked upon Mr. Collins as being the contact, andi n fact I think State Programs had jealously guarded
that role in the past, and that contacts with states
was to be through State Programs. They were theones who really knew who the contacts were. 107

sibility to implement any protective actions; and I
think that certainly was what was in my mind and in
the minds of other people as well.
The Commissioners Deliberate the Evacuation
Question

Lee Gossick did not hold Denton's view on the
EMT's authority. He believed that the Commissioners had to decide and act on the evacuation recommendation. Thus, Denton and Gossick were calling
the Commissioners with different intentions, Denton
to inform the Commission of a staff action, and Gossick to request Commission action. Commissioner
Peter Bradford was the first one reached, but soon
all the Commissioners were on the line. As theconversations with Commissioners proceeded, Denton indicated that "[w]e did advise the state police
to evacuate out to five miles," but there was a clear
i mpression that the Governor
was awaiting word
110
from the Commission.
During the time when Denton and Gossick werecalling the Commissioners, the State offices in
Pennsylvania had reacted negatively to the NRC
staff recommendation to evacuate. The recommendation was questioned by the State radiologicalhealth authorities who were in touch with the siteand saw no technical reason to evacuate. In addition, the Governor questioned Collins' authority to
speak for the NRC; he wanted to hear from thechairman of the NRC.

State Officials Are Advised To Evacuate

Collins contacted Col. Oran Henderson, theDirector of the Pennsylvania Emergency Management Agency (PEMA), at 9:17 a.m., approximately 8
minutes after Abraham had called in the 1200-mR/hreport. PEMA had previously been notified by Met
Ed that the plant had had an uncontrolled releasethat measured 1200-mR/h at 600 ft. above the plantbut only 14 mR/h at the site boundary (PEMA log).
That report, relayed to the Governor's office, hadbeen given to Abraham to verify.
When Collins reached Henderson, he asked
whether PEMA had heard about the release, andCollins was told that PEMA had received a report of1200 mR/h. With this "confirmation," Collins asked
if Henderson had issued any evacuation orders andwas told that PEMA was awaiting word from theplant. Although Denton would later say he had"leaned more toward 3 to 5 miles," 107 Collins thentold Henderson "we're recommending here that you
go ahead and evacuate ... people out to 10 miles
from that plume, in the direction of the plume."
The State, however, had evacuation plans for 5
miles, but not 10. Accordingly,1os
Henderson told Colli ns, "we'll start with 5 maybe."
Henderson alerted his colleagues in PEMA thatan evacuation order was imminent, and called theGovernor's office to advise him of the recommendation. Meanwhile, Kevin Molloy, Director of the Dauphin County Office of Emergency Preparedness,went on the radio to notify the public that there wasa possibility that they might have to evacuate. He
went on to provide advice on evacuation preparations.
Why did Collins decide to call PEMA instead of
the State of Pennsylvania Bureau of Radiation Protection? Collins testified:

And so the NRC recommendation rested with theCommission. The Commission discussed the evacuation issue, but did not vote. It was clear that thechairman had to speak to Governor Thornburgh
shortly with a recommendation. As the discussion
went on, more information came in: The release
had stopped, and the 1200-mR/h report was a local
dose rate directly over the containment building, not
an offsite location. Furthermore, the relief valve that
had lifted was not a waste gas tank relief valve, but
i nstead was another relief valve from another tank,the makeup tank.
Under questioning from Chairman Hendrie, Denton indicated that in light of new and different facts
from the site members, he did not believe there was
as much urgency to evacuate as before, but Denton
still felt that a precautionary evacuation was in orderdue to the uncertainty of the situation. On the other
hand, Brian Grimes, who was working with the
IRACT support staff, told Hendrie the "most thatshould be done, in my 111
view, is to tell people to stayinside this morning."
Of the Commissioners
present, only Bradford suggested that the conservative approach was 112
to confirm the staffs evacuation recommendation.
Hendrie realized that he[T]here was a sense of urgency, such that, I think,people believed the [1200 mR/h] reading and theywanted to do something about it. So there wasn't
too much time to do anything. If one was going to
do anything to save dose off site, the proper agency to call was Pennsylvania Emergency Management Agency, not the Bureau [sic] of Radiological
Health, because it was PEMA that had the respon-957

had to call the Governor to clarify the NRC
position-word had been passed that the State immediately needed to know what the Commission
was recommending.

the plant to pack their bags and be prepared toevacuate.
Reaction of the NRC Onsite Staff

The NRC onsite staff heard of the radio announcements about evacuation from Met Ed staff.
For 2 days, Gallina and Higgins had been the principal NRC spokesmen at the site who had periodicallybriefed the Governor and answered questions atpress conferences; yet, no one had called to ask
their opinions of whether NRC should recommend
an evacuation of areas surrounding the plant. Both
Gallina in TMI-1 and Higgins in TMI-2 immediately
tried to call NRC officials offsite to find out what was
happening. I n Gallina's opinion, an evacuation
recommendation by Headquarters

The NRC Chairman and the Governor Talk and an
Advisory Is Issued

As the matter was being considered by the Commission, Thornburgh telephoned and was put
through to Hendrie at 10:07 a.m. After a brief exchange, Hendrie stated, "it would be desirable tosuggest that people out in that northeast quadrant
within 5 milesof the plant stay indoors for the next
113
half hour."The conversation was interrupted toallow Hendrie to take information from the site received at the Bethesda response center. When theconversation resumed, Hendrie stated, "I think I
would continue to recommend that people stay inside this morning. And as our information improves,
hopefully it will, then we can see where we go fromthere. "114Paul Critchlow, with Governor Thornburgh, reported that Thomas Gerusky, Director of thePennsylvania Bureau of Radiation Protection, hadarrived in the Governor's office with radiological
data. That data indicated a maximum offsite readingof 14 mR/hr, well below what Denton had expected
earlier. 114 Gerusky had advised that-the wind was
picking up, the plume should be dissipating, and "itprobably didn't make any difference
now whether
115
people stayed indoors or not."Thornburgh then asked if there could be any
more of those releases. Hendrie told
116 him: "we mayvery well get them again, I think."
Hendrie stated,
however, that he trusted it would not happen again" without all of us knowing it in advance and
being
116
ready to anticipate what we need to do."Thornburgh asked whether he should order a precautionary evacuation in anticipation of more releases.
Hendrie replied, "it would be just as well to wait until
we know that they are going to have to make somekind of a water transfer ... and then at that time,go
116
ahead and make a precautionary evacuation."In
this fashion, Hendrie in effect countermanded therecommendation for evacuation made to State officials earlier that morning.
After he talked with Hendrie, the Governor wenton WHP radio at 10:25 a.m. to deal with the many
evacuation rumors. He said that an evacuation was
not required, but people should stay inside within a
10-mile radius of the plant. This broadcast for people to stay inside, close doors and windows, andshut down air conditioners followed, by I hour,
Molloy's WHP broadcast for people within 5 miles of[W]as just a total mistake. We were violating not
only our procedures, we were violating the State's
procedures. We were violating the Licensee's procedures by having a direct NRC Headquarters to
the Governor's Office type-completely ignoring
the technical people on site and the Commonwealthitself who were all saying-you know-'There is nor7
need to evacuate.'

White House Interest in the Accident

Around 10:45 a.m., President Carter called Hendrie. Hendrie reported the plant status at the time,
his earlier conversation with Thornburgh, and theexisting communications difficulties with the site.
The President said he would have the White House
communications group help out and added he wanted a "responsible senior official to go to take charge
at the site on behalf of the Federal Government, andthat he would regard such an officer as his directcontact at the site."
Hendrie responded he had already suggested to
Denton that
he go and that "[Denton] was the best116
person."Jody Powell at a 1:36 p.m. press conference said the President had told Hendrie, "to be
sure that if they [NRC official] erred, to err on theside of caution and safety and to make sure that if
there was any perception of a need for additional
119
assistance that we be informed of it immediately."
Commissioners Reconsider the Need for Evacuation

The Commissioners and the staff continued to
discuss Hendrie's advice to the Governor to stay indoors as well as the current uncertain conditions in
the plant. Case noted "the information you will havewithin the next hour maybe [sic] as sketchy or lessthan you had the last time. The plant is in a tenderstate, not really knowing what they are doing and I
95 8

have no confidence they will know come thenext .... "120After Hendrie had reported his conversation with
the President to the Commissioners, further discussion concerning evacuation ensued. Commissioner
Bradford brought up the subject of pregnant women, which he had discussed on Thursday with oneof the members of his personal staff.121 If no general evacuation was necessary, what about an evacuation advisory to those who might be particularly
sensitive to radiation exposure or those who simply
do not need to be in the area? According to Hendrie:[I]t boiled down to children and pregnant womenwhere they reasonably could leave, had someplace
to go, on the basis that those elements of the population are known to be sensitive to radiation exposure.122
Although there was no formal vote, Hendriethought it was the sense of the Commissioners that
it would be prudent to recommend to the Governor
an advisory for pregnant women and children tol eave the area. Hendrie thus believed the recommendation was in effect a collegial decision.123
Governor Issues an Advisory to Pregnant Womenand Preschool Children
At 11:40 a.m., Hendrie called the Governor. Hendrie began the conversation with a description ofplant status and noted the possibility of further
releases.
The
Governormentionedthat
Pennsylvania's Secretary of Health was concerned
about the special sensitivity of pregnant women andchildren and asked for Hendrie's comment. Accordi ng to Gerusky, who was present, Hendrie said "If
my wife was pregnant and I had small children in thearea, I would get them out because we don't knowwhat is going to happen."124 Hendrie and Thornburgh discussed how far out-1, 2, or 3 miles.
Gerusky suggested 5 miles because the State had
evacuation plans for 5 miles, and the matter was
thus settled.
At 12:30 p.m. Governor Thornburgh held a press
conference in which he announced:
Based on advice of the Chairman of NRC and in thei nterests of taking every precaution, I am advisingthose who may be particularly susceptible to theeffects of radiation, that is, pregnant women andpreschool age children, to leave the area within a
5-mile radius of the Three Mile Island facility until
further notice. We have also ordered the closing of
any schools within this area. I repeat that this andother contingency measures are based on my belief that an excess of caution is best. Current readings are no higher than they were yesterday. How-ever, the continued presence of radioactivity in thearea and the possibility of further emissions leadme to exercise the utmost of caution. 25
Headquarters-A Growing Hydrogen Bubble
Concern
The bubble concern first arose late Thursday.
Tests by the plant staff indicated that there existed
about 1000 cubic feet of uncondensed gas in thereactor coolant system. Through Thursday nightand Friday morning, the system analysts debatedthe meaning of this condition. Finally, the high coreoutlet temperature readings, the high radioactivity
levels in the coolant, and the discovery on Friday of
a containment pressure spike at 1:50 p.m. on
Wednesday,126 led to the conclusion that most ofthat 1000 cubic feet was hydrogen. It was believed
to have been produced by massive overheating of
the core.
Early on Friday morning, Roger Mattson and his
staff, principally under Robert Tedesco, were trying
to devise means to remove the bubble from thereactor coolant system. Staff members feared thatthe bubble could inhibit core cooling. There wasalso concern about a possible hydrogen burn in thecontainment building. Conservative calculations
showed that releasing the bubble entirely to thecontainment building could raise the hydrogen concentration in the building by about 2% (Appendix
111. 4). If there was a total of 4% hydrogen in thebuilding, a burn might be expected.
As Friday morning progressed, the bubble became an evacuation consideration. With news of
uncontrolled releases from a full waste gas decay
tank, Mattson worried that the plant staff would beforced to depressurize. If they did depressurize, thebubble would simply expand and uncover the core
once again. Mattson's concern, first expressed to
EMT members, came to a head shortly after noonon Friday when Mattson telephoned the Commissioners to describe the problem. Mattson had
played little part in the 1200-mR/h evacuation debate, but he strongly believed the bubble problem
justified evacuation. As he put it to the Commission:
I' m not sure why you are not moving people. Got
to say it. I have been saying it down here. I don't
know what we are protecting at this point. I think
we ought to be moving people. 127
Hendrie was apparently not persuaded by
Mattson's plea. He sent him back to work with an
i nstruction to keep the Commission posted.
Although Mattson's prime concern was that theplant staff would depressurize, no one had passedon this concern to Met Ed officials. Mattson ap-

95 9

pears to have believed that it 128
was up to the EMT
members like Case to do so.
Case, however,"assumed" Mattson "was making those kind of con129
tacts."
By Friday evening, Hendrie was worried about
the bubble. Earlier in the afternoon, Governor
Thornburgh had asked Hendrie about the possibilityof the bubble exploding. Hendrie's reply was:" There isn't any oxygen in there [reactor pressure
vessel] to combine with that hydrogen so the130
answer as far as I know is pretty close to zero."
However, Hendrie was nagged by the suspicion thatradiolysis would ionize the water and produce more
free oxygen inside the reactor pressure vessel, oxygen that might combine with the hydrogen in the
bubble (Appendix 111.4).
Hendrie's concern led to a new direction for the
bubble work-investigation of the accumulation ofoxygen inside the vessel and the attendant risk of
explosion. Previous efforts to calculate the generation of hydrogen and oxygen by radiolysis in a
depressurized system like the containment building
would now be paralleled by similar calculations for asystem with a substantial hydrogen overpressure.
The former calculations were focused on the buildup of hydrogen, the latter on the buildup of oxygen.
Friday at midnight, Hendrie and Commissioners Gilinsky, Bradford, and Ahearne considered the problem. Hendrie was aware that an overpressure ofhydrogen normally suppresses the radiolytic production of more hydrogen and oxygen in a systemsuch as this, but this system was not normal; it wasfilled with water contaminated with fission products
from a badly damaged core.
I nteragency Involvement Mushrooms

I n the aftermath of President Carter's call to Hendrie, White House officials began to take an activerole in the TMI response. Jack Watson, Assistant to
the President for Intergovernmental Affairs, wasdesignated by the President to coordinate all
Federal agency activities in the response. Watson
immediately organized a Federal interagency planning meeting, which was held at 1:30 p.m. Friday
afternoon in the White House Situation Room; it was
attended by representatives of the White House, theFederal Disaster Assistance Administration, theFederal Preparedness Agency, the Defense Civil
Preparedness Agency, the Department of Defense,
the Department of Energy, and Chairman Hendrie
representing the NRC. At this meeting, Hendriebriefed the attendees on the status of the damaged
reactor. He speculated that it might conceivably benecessary to evacuate as far out as 20 miles. He"distant
selected
thisnumber
from
accident
calculations"andnotrecollections ... of131
from NRC staff recommendations.
During the remainder of the day, there were frequent conversations between the NRC, the WhiteHouse, and Federal agencies concerning the situation at the plant. By the end of the day, the Environmental Protection Agency (EPA) and theDepartment of Health, Education, and Welfare(HEW) had sent representatives to NRC's operations center in Bethesda to facilitate the exchange
of information.
At 5:00 p.m. Commissioners Gilinsky and Bradford went to brief EPA and HEW officials about thestatus of the reactor and radioactivity releases. At
that meeting, they indicated that officials mighthave132
about 6 hours advance notice of a meltdown.
An interagency meeting also was held Friday
night at the Capital City Airport near the site. It was
i nitiated by DOE officials who saw a need to better
coordinate the environmental monitoring and datacollection activities of the various government agencies working at Three Mile Island. The meeting wasattended by representatives from the State, EPA,
HEW, and the NRC133 At that meeting, DOE wasdesignated to coordinate all of these activities andto ensure that all involved organizations were kept
currently informed. DOE's Region I office carriedout this responsibility.
Onsite Activities After the NRC's Evacuation
Recommendations

At about 12:30 p.m. Friday, Boyce Grier, Directorof NRC's Region I office, was told by Headquarters
to go to the site to supervise IE personnel. Denton
was also preparing to fly to the site from Headquarters; his helicopter arrived at the site at 2:00 p.m
By late afternoon, NRC had 83 people at the site51 from the NRC's Office of Inspection and Enforcement, 25 from the Office of Nuclear Reactor Regulation, 4 from the Office of State Programs, and 3
from the Office of Public Affairs.
When Hendrie told Denton to go to Three Mile Isl and, he informed him simply "to take charge of NRC
activities at the site," nothing more specific thanthat.1Thus, Denton's plans were only loosely defined. He would "take [my] normal role as head of
the safety review of the plant and direct actions in
135
When he left, Denton had not yet "adthat area."
dressed (the] issue" of whether he would have authority to make evacuation recommendations andindeed "if I had felt the need to make further recommendations once I arrived on the scene, I would
have done so back through the Commission
960

134

again."Nor did Denton go to the site with any"firmly defined view" regarding
his relationship with136
the Headquarters EMT.
Denton had not had time
to make organizational plans concerning the IE andNRR personnel over whom he would "take charge"at the site. 137 Nor had he had time to decide whatworking relationship to establish between the NRC
team and the Met Ed personnel manning the control
room 1 38 All of these important matters would haveto be worked out in the days that followed.
After he arrived at TMI and surveyed the situation, Denton's previous impressions changed in a
number of respects. Denton found that he had previously underestimated the degree to which Met Ed
personnel were anticipating and working to avoid
potential problems. As Denton reported to theCommission Friday afternoon:

Governor. Denton had expected to manage the
NRC's onsite response activities. He and Stello had
agreed that they would split this assignment, Denton
working the day shift and Stello the night shift.
Denton had not "even perceived of the comingpress aspects. It had not even been discussed withme when I left." 141 But Denton soon found that hewas spending almost all of his time acting
as a142
spokesman and transmitting information:

Q: Am I correct in my understanding that the problem with that became that you were simply toobusy....
A: Yes.
Q: [A]ttending to other things, so Vic Stello wound
up having to be the boss in your place when you
were going to be the boss?
A: That's right. It quickly ended up with Vic [Stello]working around the clock. And we did subsequently modify the structure by bringing in, I
think, Denny Ross and Dick Vollmer as sort of
the nominal day-to-day, shift-to-shift coordinators and leaving Vic and Roger Mattson [who arrived Sunday] to be the normal decision making
heads. And my role got to be the one of
spokesman for the agency, after a few days.

I think one of the things that at least is encouraging,we kind of had the feeling this morning, back there[at Headquarters] that the licensee doesn't evenrecognize the problems that we're facing with regard to the bubble and damage and what might
happen if we were to lose vacuum and so forth andthe brief discussions we've had, they seem tocomprehend the same sorts of problems and havepreliminary plans to cope with it. This takes a little
bit of the pressure off the immediacy of my concern
this morning. Their people do seem to be quite
aware of the same kind of problems that we were
having this moming.'

Denton and a larger onsite NRC team brought
about a major improvement in NRC's onsite evaluation activities. For one thing, NRC began to require
Met Ed to describe in advance what actions it proposed to take in plant operations, before initiatingthem. For another, NRC could now effectively monitor and evaluate all proposed recovery operations.
John Collins, who arrived with Denton at the site on
Friday, said:

Although he had favored evacuation Friday morni ng, Denton's onsite view was that evacuation was
unnecessary. In his deposition, Denton explained
why: 140

A: I rely heavily on a very competent professional
staff. And I don't think they were-they weren't
feeling all that comfortable Friday momingwhen I talked to some of the same people thatwent with me. And after getting the people up to
the site and having them look into their various
areas that they're specialists in, and finding thatthey were much more convinced of the stabilityof the situation.

[T]he program for NRC to review [procedures] wasinitiated at the time we arrived on site. That waspart of the plan by which Mr. Denton and Mr. Stello
and Mr. Vollmer, that we would be engaged in reviewing their emergency procedures.

Collins believed this formalized procedure commenced sometime Friday. It took time, however, forthe team to become property organized to avoid unnecessary overlap and duplication. For example, at
one time there were as many as 10 NRC people inthe control room. 144

I was projecting the fimage that I was gettingfrom my professional staff after having seen thepatient themselves....
Q: But had the patients' condition changed, in retrospect?
A: No, I don't think the patients' condition hadchanged. But our perception of it certainly
changed.

d. Saturday, March 31, 1979

After arriving at the site, Denton also discoveredthat his personal role would be different from what
he had expected. There were immediate pressureson him to talk to the press and brief Governor
Thornburgh and, indeed, later that night he would
participate in a major press conference with the

The NRC Onsite Organization and Activities

By early Saturday morning, the onsite strength of
the NRC had grown to 51 people and would growmore. The outline of an onsite organization had begun to develop. Since his arrival on Friday, Denton
96 1

was the designated leader of all NRC activities onsite. Under him, Denton had two somewhat parallelteams, divided along NRC office lines-an IE teamand NRR team. Boyce Grier, the Region I Director,
was in charge of the IE team. Since Denton andGrier were old friends, Denton assumed from theoutset: "[T]hat [Grier] and I would get along fineand that he would direct his staff in doing what hetraditionally did, and that we would work out things
145
as we went along."
The IE personnel at the site, however, were neverreally integrated with NRR staff. According to Denton, the IE personnel on site:

I n his deposition, James Higgins provided a clear
picture of the organizational difficulties from the perspective of an IE inspector in the control room: 150[ We] did have some difficulties with who was doing
what, what IE was doing, what NRR was doing, who
was doing the procedures, who was reviewing
them, who was looking at the operational aspects,
who we would talk to when we had a particular
problem, what our role really was. I think almost
every afternoon when the Inspectors who were in
the Control Room, we went out to talk to our supervisors, we would say, okay, what are we really
supposed to be doing here and what is our role andhow are we supposed to treat these different aspects and we would discuss it with them.
It was not a situation where we-we weren't
getting told anything but it was a developing situation and it was very, very difficult, very tenuous.
We were continually trying to determine where we
stood vis-a-vis the licensee and NRR. It was reallynot clearly laid out.

[ R]emained under [Grier's] direction. We never did
i ntegrate the two [staffs] completely. But we would
attend each other's staff meetings, as I recall, andwhatever they wanted us to focus on, we would.
And if we wanted some measurements from themon the environmental side, they would. But theyfunctioned as a separate unit pretty much thewhole time.'

Q: Did there come a time when it was clearly laidout?
A: No.

As Grier recalls the relationship between NRR andI E onsite personnel, the NRR personnel took chargeof all in-plant activities. 147 Although IE personnel
remained in the control room, IE was relied upon"principally to provide environmental information andbriefings. We supplied [Denton] regularly with briefi ng information either written or oral in terms of en148
vironmental status."
I n his deposition,149
Grier admitted that everything
did not go smoothly:

0: During the first week, let's say?

A: No. I was there for two additional weeks in theend of May and even then it wasn't clearly laidout.
As time went on, Denton's relationship with the
EMT at Bethesda began to take a more distinct
shape. As Denton put it:

I didn't have a firmly defined view on that topic
when I left Bethesda. After I had gotten to the site,
I did quickly come to believe that the important decision should be made at the site and that weshould rely on the EMT to continue the transmittalof information aspects and do detailed calculations.
But I found that I was in a much better position tounderstand and make recommendations about
things once I was at the site and getting firsthandi nformation than I was back in Bethesda, operatingon fragmented information. So I think over the few
days, maybe even a smaller time interval, my pert01
ception about the role of the EMT changed.

Q: I get the impression from talking to you thatmaybe the IE/NRR interface of relative roles wasnever clearly defined at the site?
A: That's correct. My feeling-when we arrived
onsite on the Friday evening there was direction
to set up the organization .... Now, there wassome integration in terms of the IE people were
working within prescribed groups but-also contain NRR people. I guess I had some difficulty inthat I didn't feel their organization was everclearly defined. And I didn't know how to fit myorganization in with theirs. That is one factor.
The other factor is that, of course, we have
our traditional roles of NRR reviewing and approving procedures, if you will. And IE having
the role of verifying. Now, it-in my view the organization could have been continued to be set
up along those lines that-if those in charge had
made use of the IE personnel in that role.

I n effect, many of the EMT's responsibilities weretaken over by Denton at the site.
Many of the NRR onsite staff members worked
through Friday night and Saturday thinking out different scenarios and situations, and considering alternative actions to cope with events should theyoccur. Personnel worked on how to reduce the sizeof the gas bubble in the core and how to install andoperate a hydrogen recombiner to remove hydrogenfrom the air of the containment building. Anotherconcern was the possibility of equipment failure due
to prolonged exposure to high levels of radiation.
Other staff members continued to oversee the actions taken by Met Ed to get the reactor safely to[But] I had the feeling that the use of the E people was just not being done. I can understandthe fact that you know your own people, youhave confidence in them. You can rely on them.
And that perhaps affects NRR action because
they know what to expect of their people. And
they don't know the IE people.
96 2

Ba i n the sample to be characteristic of gas
andreleases and not of significant fuel melt. The consensus following receipt of the assay results wasthat the core was not damaged as badly as had
been feared.
A sample of containment building air that was
analyzed Saturday morning showed concentrationsof hydrogen (1.7%), oxygen (16.5%), and nitrogen(91.8%). A sample taken later at 3:00 p.m. measured 1.9% of hydrogen. Thus, the hydrogen concentration appeared to be increasing. Later, when
the hydrogen recombiner was started, concern of a
possible hydrogen fire or explosion in the containment building was alleviated.

cold shutdown. The NRC had established that Met
Ed would not undertake new initiatives without informing NRC and obtaining NRC's approval.
Whereas Met Ed had expressed concern with thepresence of too many NRC inspectors in the control
room the day before, early on Saturday the plantsuperintendent
asked that NRC presence not be re152
duced further.
By noon Saturday, Met Ed apparently believed it
had a way to transfer hydrogen gas out of the reactor coolant system into the reactor building air
space. However, Denton was holding up use of thatpath until he had "a better handle153on the hydrogensituation within the containment."
The plant wasdegassing slowly, and GPU and Met Ed apparently
believed the bubble was shrinking, but some at NRC
were doubting that. At midmorning the bubble had
been reported to be about the same size as it had
been before. New calculations by Met Ed at 2:40
p.m. indicated the bubble size had decreased somewhat to 880 cubic feet at 875 psig. At 4:20 p.m.,the size was recalculated to be 621 cubic feet at
875 psig. An hour later at 5:35 p.m., the bubble
was calculated to be larger in size-742 cubic feet.
Continuing efforts were being made to reduce thesize of the bubble by venting the pressurizer into
the containment building atmosphere.
During a noon status report to the Commissioners back at Headquarters, Denton expressed concern that since Met Ed was spread very thin theymight not be able to cope with new problems from amanagement perspective. He indicated that theutility's operation was basically a "fire fighting
operation." William Kreger of Denton's staff had estimated that Met Ed needed perhaps 50 more technicians to operate effectively. Denton and the Commissioners apparently agreed that efforts should bemade to encourage and to assist Met Ed in getting
additional industry experts to the site.
Denton also explained that he then foresaw only
two reasons for evacuation-loss of the existingcooling mode and resultant degradation of the situation, or a deliberate planned change in the coolingmode. Denton was aware of the concern that thehydrogen bubble might explode and was awaiting
firmer analysis of it by Headquarters personnel. But
he seemed less troubled about
it because of the154"lack of an ignition mechanism."
The NRC staff continued to monitor plant conditions. Fuel temperatures were still coming down; all
the core exit thermocouples were back on scale.
(The highest recorded temperature was 890 °.) A
reactor coolant sample taken the day before wasanalyzed at the DOE's Bettis Laboratory. The
89
Sr, 9oSr,
results of the assay showed amounts of

1 40

Communications Between the Site andHeadquarters

Communications between the site and Headquarters were significantly improved Saturday with thepresence of Harold Denton and the additional NRC
forces that had arrived at the site. It was now possible to assign more people to the tasks of gatheri ng and evaluating information and of manning thetelephones. The manning of phones by new teammembers also lightened the burden of those NRC
staff members who were responsible for gathering
or evaluating information. As Higgins put it:

We essentially had a phone talker. So that they
could take all the questions from Washington andcome to me, and I could get the answers and I
could be spending all my time with keeping up withthe situation and discussing plant status with thesuperintendent and so forth in the Control Room,and I didn't have to spend fifteen minutes at a shoton the phone also. I could j ust do that through theperson who was right there. That helped me out alot.1 65

In addition, NRC Headquarters no longer called
the site every 10 minutes when an information needarose; instead, Headquarters called at 1-hour intervals with consolidated requests. The installation of"dedicated" telephone lines by the White House also
appeared to help matters. Nevertheless, communications problems still existed. For an hour at aboutnoon, for example, communications between thesite and NRC Headquarters were lost.
NRC Activities Off Site

At Headquarters, officials spent less time
" managing" the accident and more time providing
support and advice. Activities at the Headquarters
response center included answering inquiries fromthe public, the White House, and Congress; consid96 3

ering ways of reducing the size of the hydrogen
bubble within the core; analyzing the possibility of ahydrogen explosion in the core; arranging deliveryof needed equipment to the site, including leadbricks to shield the hydrogen recombiner and amechanical robot to enter high radiation areas; andcontingency planning.
I n response to a site request for lead bricks toshield the hydrogen recombiner, dozens of calls
were made by Headquarters and Region I to obtaina large supply. As a result, some 200 tons of leadbricks were obtained from such places as NL Industries, Altoona, Pa.; the National Bureau of Standards,
Gaithersburg, Md.; DOE's Bettis Laboratory, Pittsburgh, Pa.; DOE's Brookhaven National Laboratory,
Long Island, N.Y.; National Naval Medical Center,
Bethesda, Md.; Nine Mile Point Reactor, Oswego,
N.Y.; and the Armed Forces Radiobiology Institute,
Bethesda, Md. The bricks were located by the NRC
staff and prompt arrangements were made for military transport of these to the site. In less than 18hours after the need was identified, the required
bricks were in place surrounding the hydrogen
recombiner permitting it to be placed in operation.
I n response to a site request for a mechanicalrobot to work in high radiation areas, two were located by the NRC staff. One was found in Oak
Ridge, Tenn., at the Y-12 plant and one was at theEglin Air Force Base in Florida. Arrangements werethen made for their delivery to the TMI site.
In addition to activities directly related to TMI, the
NRC staff had prepared and was discussing thecontent of orders to operators of five other Babcock
and Wilcox plants to ensure their continued safe
operation.
At 8:00 p.m. on Saturday, Commissioner Gilinsky
brought a new request to the EMT staff. He asked
Edson Case to prepare contingency evacuationplans and to give them to him in writing by 6:00 a.m.
Sunday. Plans and criteria were to be established
for different situations that might arise. Dr. Stephen
Hanauer was chosen to head up a team and they
worked through the night on this task.
According to Commissioner Gilinsky, on Friday
night he feared that "we just didn't have a grip on
what sort of evacuation we might be thinking about,156
if in fact it came to that."
As a result, he had"some old documents" pulled together "on the nature of releases and how far they would extend andso on, what the various profiles would be." 157 Saturday afternoon, the need for contingency evacuationplans was suggested at a White House meeting attended by Gilinsky; Jack Watson of the WhiteHouse staff asked that some contingency evacuation plans be prepared by the NRC. It was this re-quest that led to Gilinsky's 8:00 p.m. directive to thestaff at Headquarters.
Analysis of the Bubble Continues

As the bubble analysis grew in complexity, more
and more people were called in to work on it.
Hendrie's nagging concern about possible oxygen
accumulation and an explosion inside the reactor
vessel led him to press a number of staff members
to work on this. The work was divided as it grew inscope, with Dr. Mattson
apparently viewed as thel58
staff coordinator.
NRC officials on site were awareof Headquarters' concern about the potential explosiveness of the bubble, but attended to more immediate problems at the site.
About 2:00 a.m., Wayne Lanning of the NRC's
Office of Nuclear Regulatory Research (Research)
was put to work to determine the probable resultsof an explosion in the reactor vessel. Lanning
asked L. Ybarrando of EG&G-Idaho to do the calculation; Lanning at this time was already deeply involved in special tests being run on the Semiscale
facility in Idaho at NRC request, exploring ways toflush the gas bubble out through the pressurizer.
B&W was keeping in touch with these tests andwas also involved with the NRC's interest in the potential forces of an explosion inside the reactor
pressure vessel. At 5:30 a.m., B&W gave Warren
Minners the results of its analysis. The B&W
analysis indicated an explosion could generate ani nternal pressure of 14000 pounds per square inch
( Appendix 111.4). At about 7:00 a.m., various
members of Research asked Idaho National Engineering Laboratory (INEL), Battelle-Columbus, andSandia Laboratories to calculate the hydrogen burni ng and explosion potential.
At 10:50 a.m., Roger Mattson discussed the situation with Robert Tedesco and gave Tedesco thefollowing list of questions to ask Westinghouse andGeneral Electric-Knolls Atomic Power Laboratory(GE-KAPL).
1. What is the gas evolution rate?
2. How soon would a flammable concentration bereached?
3. Is oxygen stripping out of the coolant and goingi nto the dome of the reactor pressure vessel, i.e.,entering the bubble?
4. Is oxygen staying dissolved?
5. What does it mean as we go to the flammability
li mit?
6. How does flammablity change at high pressure?

As early as Saturday morning, some thought that
explosion of the bubble might not be a problem be964

cause of a low oxygen evolution rate. During themorning, NRR's Warren Hazelton (who was working
on the effects of hydrogen on the vessel's steel
walls), convinced that others' estimates concerning
the evolution of oxygen into the bubble were far too
high, consulted two experts by phone. John Weeks
of Brookhaven and Paul Cohen (ex-Westinghouse
and Bettis, retired) confirmed Hazelton's view thathydrogen overpressure would greatly inhibit oxygen
evolution. Hazelton passed on his information within
the agency, but somehow his efforts led nowhere.
Mattson never learned of Hazelton's opinion.
Investigation of the oxygen generation rate led
INEL to consider data from two dissimilar systems,
the Cooper plant (a BWR) and the Advanced Test
Reactor (a low-pressure system). Although INEL's
i nvestigation indicated that oxygen would be generated, the experts emphasized to Headquarters
personnel in Research that their conclusions werevery conservative.
About midday, Saul Levine, Director of Research,
spoke with Robert Ritzmann of SAI. According to
Levine, Ritzmann advised that a person could calculate 1% oxygen generation per day without consideration of bubble back pressure but 1% wasprobably too high-the proper rate was probably
one-tenth of 1% and could be zero. Levine says that
he passed on Ritzmann's opinion, together with information obtained by Research from INEL, to Mattson. Mattson confirms talking to Levine at midday
Saturday. Mattson's contemporaneous notes, however, suggest that what Mattson heard Levine say
about Ritzmann's opinion differed materially fromwhat Levine remembers telling. Mattson's notes
read:

recombination of hydrogen and oxygen in the bubble was not a strong possibility, and Westinghousei ndicated that at low coolant temperatures recombination in the coolant was not likely. At this time, thebulk temperature of the reactor coolant was down
to about 300° F. About 4:00 p.m., NRR personnel
again talked with KAPL and, based on that conversation, NRR officials concluded that the bubble wasnearing the lower range of flammability and that it
would take about 2 weeks to reach the lower detonable limit. This was relayed to Mattson, together
with KAPL's view that there was no evidence ofself-ignition.
After Chairman Hendrie's 2:45 p.m. press conference, the Commission met in Bethesda to discuss
the bubble problem with Mattson and others. Mattson reported the staff's concern about oxygen
buildup in the bubble and, apparently using his notesof Ritzmann's figures, said that the bubble then held
2% to 3% oxygen and that the danger points were
8% to 9% for ignition or burning and 2 or 3 times
higher for detonation or explosion. It would takeabout 5 days to reach 8%. Mattson indicated that
his group was looking for a way to vent the gas
bubble by heating a control rod pressure housing inorder to crack it open, but they feared that themethod would ignite the gas. There was, however,some encouraging news-three of the four reactor
coolant pumps were now operable. Mattson's biggest concern, shared by Levine, was that the plant
i nstall additional decay heat removal equipment as
quickly as possible. The hydrogen bubble problem
was tolerable because of the belief that it was justapproaching the flammability point and still someway from the detonation level. During the discussion of the hydrogen problem and how to cool down
the plant, Mattson withdrew his previous recommendation to evacuate people from areas surroundi ng the plant. Mattson no longer perceived thenear-term necessity to depressurize or to take other action that might expose the already damaged
core.
Shortly after 6:00 p.m., experts at KAPL, believi ng that the back reaction would absorb the oxygenat those plant conditions, recommended holding thehydrogen bubble in the reactor coolant system andcontinuing to degas with the system pressure held
high. Still, NRC personnel feared oxygen evolution
and explosion.

Levine reports that Ritzmann ... says 2% oxygen
present now... (the rate of production from gam-mas could be 10 times higrier, but Ritzmann doesn't
believe it).

Ritzmann also tells Levine that mixture ignition
could occur at 8% to 9% oxygen, with detonation
higher by a factor of 2 or 3. Levine also reportsthat Sid Cohen (INEL) says 5% oxygen in 4-5
days.... [Emphasis added.]

At approximately 2:15 p.m., Mattson relayed toChairman Hendrie his understanding of Ritzmann's
opinion, together with the preliminary advice received by NRR from Knolls Atomic Power Laboratory (KAPL). Hendrie was at that time preparing toconduct a press conference at Headquarters; thisconference and its repercussions are discussed
below.
By 2:30 p.m., NRR personnel at Headquarters
also were getting some feedback from Westinghouse and GE-KAPL. KAPL advised that the

The Public is Concerned About the Bubble

At 2:45 p.m., Hendrie held a news conference in
Bethesda. He reported, among other things, thatthe bubble would need to be removed from the
96 5

reactor, but it would be some time before there
would be any possibility of a flammable condition. In
answer to a question on evacuation, he indicatedthat evacuation was a possibility that would have to
be kept in mind in considering the steps to be taken, that evacuation might turn out to be a prudent
precautionary measure, and that evacuation would
be considered for people within 20 miles of the site.
Later in the afternoon at 4:25 p.m., Hendrie called
Governor Thornburgh about the evacuation question. At that time, he reassured the Governor that
his remarks about a 10- to 20-mile evacuation weremade in answer to questions about a situation hedid not expect to develop. Hendrie said that "theassessment here is that the plant is stable" and that
evacuation was not called for. 159 I n answer toThornburgh's question, Hendrie advised leaving in
effect the advisory on pregnant women andpreschool children, at least overnight.
Saturday night, the Associated Press issued abulletin, which had been cleared with NRC Headquarters, concerning the bubble. However, many
people interpreted the bulletin as saying that the
bubble was unstable and could explode momentarily; near panic ensued near the site as people began
to evacuate surrounding areas without awaiting notice from public officials.
At about 11:00 p.m., NRC's Karl Abraham called
NRC Headquarters to report that the Governor's
Press Secretary, Paul Critchlow, had just walked
i nto his office and in a loud voice told him, "Carl,
you'd better tell your people in Washington to keep
their 'blankety blank' mouths shut because theGovernor is160
getting pretty sick of it. You're causinga panic...."At about the same time, Edson Case, who had
confirmed161the substance of the AP story before it
went out,
was manning the EMT room when aWhite House official called to urge that Headquarters no longer handle any press inquiries. Casesays he subsequently discussed the White
House
162
call by telephone with Chairman Hendrie.
Case
i nsists that "we didn't take orders from the WhiteHouse. I do 163
what the Chairman and I thought weought to do."According to Case, he and Hendrie
eventually decided to transfer all press calls to thesite after Case indicated that he would "be glad to
get rid of this headache. Let's go along with it." 164Case did not confer with NRC165officials at the site
before this decision was made.
NRC Contacts with Government Organizations

Harold Denton established a schedule of calling
Governor Thornburgh with briefing reports every 2
96 6hours. He also held a joint news conference with
the Governor at 11:00 p.m. Saturday to answer
questions concerning the possibility of a hydrogen
explosion in the core.
Saturday night, Commissioners Gilinsky andBradford attended a meeting with representatives of
all involved Federal agencies, held in the WhiteHouse Situation Room, to discuss the total Federal
effort being applied in response to the accident. It
was during this meeting that Watson asked Gilinsky
to prepare contingency evacuation plans-a requestthat led to the staff's all-night efforts at Headquarters.
Throughout Saturday, NRC gave frequent status
reports to congressional oversight committees, interested Congressmen, other Federal agencies, andinterested State officials in surrounding States.
e. Sunday, April 1, 1979
Bubble Analysis at Headquarters

Early Sunday morning, the Headquarters Incident
Response Center was crowded with people; Roger
Mattson and Darrell Eisenhut at the center spokewith Denwood Ross at the site. They reported to
Ross that it had been conservatively estimated thatthe oxygen content of the bubble was increasing by
1% per day. There was some discussion of blanketi ng the makeup water, which was pumped in during
the degassing process, with inert gas to reduce theevolution of oxygen from the makeup water. Reviewing a host of problems, Mattson concluded thattaking any steps to cool down would be more risky
than the present condition.
At 8:00 a.m., Merrill Taylor at the site, in
response to Victor Stello's request the night before,
advised Stello that an explosion in the reactor
vessel was an extremely remote possibility (Appendix 111. 4). Taylor, himself not a radiochemistry expert, based his opinion heavily on his knowledge of
special work at Oak Ridge National Laboratory
about 10 years before. Taylor believed there would
be no net evolution of oxygen into the bubble andtherefore little chance of explosion. However, ashort time later, at the NRC Headquarters, a different view was formed.
At 9:15 a.m., Mattson had just returned to the
response center and was preparing to leave for thesite with Chairman Hendrie. Mattson was briefed by
Saul Levine, Robert Budnitz, and Thomas Murley, allof whom had worked on the hydrogen explosion
concern. As reflected in notes they made at theti me, their consensus was that oxygen was increas-serious concern about the hydrogen explosion
problem, but that it would be "days or a week" before there was a threat of explosion.'
Meanwhile, back at Headquarters more consideration was being given to the problem, concentrating on the effects of a hydrogen explosion in thepressure vessel, not its likelihood. At 1:45 p.m., theCommission, minus the chairman, met in the
response center to hear a briefing from Robert Budnitz on the problem. Budnitz dwelt on the possibilities of ignition and the effects; he gave little attention to the generation of oxygen. At this meeting,
the Commissioners tried to determine how quickly
the local authorities could begin an evacuation.
They were told that the Pennsylvania National
Guard and State Police were on a 4-hour alert
status and that the Governor would not increasethat level of alert. The consensus of the Commissioners was that the uncertainties about hydrogen
explosion potential, combined with the alert statusof the local authorities, was sufficient to warrant aprecautionary evacuation. The Commissioners decided to contact Chairman Hendrie with this view. In
effect, the Commission had decided to recommend
evacuation to Hendrie, deferring to his presumably
better knowledge of the situation at the site.
At 3:00 p.m., Commissioners Kennedy, Ahearne,
and Bradford spoke to Hendrie from the Response
Center. Hendrie told them for the first time that ahydrogen explosion was not a problem, inasmuch
as the assumptions concerning oxygen evolution
were wrong. Hendrie, persuaded by Stello, told
them that he expected expert confirmation of thisshortly from the naval reactors people. Stello,meanwhile, was vigorously seeking confirmationfrom DOE's Bettis Atomic Power Laboratory (a naval reactor laboratory) and GE-San Jose (BWR
designers). Commissioner Kennedy told Hendriethat the Commissioners recommended he discuss
the matter with the Governor and advised that theGovernor call for a precautionary evacuation out to2 miles from the site. In an ensuing discussion,Commissioner Bradford stated that evacuation was
warranted by the general uncertainties, not just thehydrogen explosion problem. Hendrie agreed to call
Gilinsky, who had gone to the White House.
Shortly after Stello called Bettis and GE-San
Jose at about 3:00 p.m., both experts confirmed his
view-little or no oxygen was being generated into
the bubble. Mattson was present when Stello firstcalled these experts and he offers one possible explanation for Stello's quick success:i ng at 1% per day and had already reached about
5% in the bubble, the "realistic" flammability limit; 11%
to 12% was the "realistic" detonation limit; and 900"F
was the threshold for spontaneous combustion.
Mattson describes how these numbers were obtained:166

I said, "Okay, I am going to be with the President ofthese damned United States in a few minutes, andit's time to stop this wishy-washy all over the place.
What do we think?" Maybe I was feeling my oats. I
had had some sleep.
And people talked for a few minutes, and it was
kind of all over the place that morning again. I said,"All right, I am going to write some numbers down,
and you tell me what's wrong with these numbers."
And I started down the list.
f f f

I will not characterize [the numbers] as whether

they were conservative or a best-estimate. People
I have talked to have talked to me with such vigor
they have destroyed any personal recollection I
have of them. Everybody in that room knew how
the numbers were going to be used. They knew towhom I was going to carry them, and they knew theimportance of them, and they agreed to thosenumbers.

Saul Levine, who had become convinced Saturday night that there was "no significant oxygen in
the bubble," has a different perspective concerningthese conversations: 167

I started to try to explain to [Mattson] the ins andthe outs of the conversations that I had been having with Ritzmann that led us to the tenth of a percent per day.
f f f

He kept repeating he had to leave almost momentarily, because the Chairman and he were going to
the site. The President was coming and the Chairman had to be there for the President.
He said-he cut short my explanation and asked
what is the worst possible that it could be.
And I said, well, the worst possible is an increase of 1% per day.

[ A]nd then he said, "Well, okay. Now, what's theflammability limit?"
I said it's fIve percent at this pressure and temperature and the explosive limit is somewhere
between ten and eleven percent and therefore wehave a week or so before you get to the explosiveli mit as an upper bound. But I didn't-for upperbound purposes, yes, but I didn't believe that was
reality.

At noon, Mattson and Hendrie arrived at the airport in Middletown and were met by Stello and Denton. Stello firmly believed that the Headquarters
consensus was wrong, that the high hydrogen overpressure in the system was recombining the oxygen. When Denton and Stello briefed President
Carter, they apparently told him that the staff had aWell, I heard him ask the question, and it had
something to do with the way the question was
asked. He said, "We've got this question about

96 7

whether oxygen can be generated and cause an
explosion, and a lot of people have been working
on it and they come up with an uncertain answer
that oxygen could be generated quickly; well, I
don't think it can; I think the hydrogen will suppress
it; and we need to decide this difference of opinion
very quickly; and I think in normal operations they
have to suppress radiolysis; and I think the way
they do it is with hydrogen; and so I want ananswer and I want it within two hours and I want it
firm and conclusive. I don't care who you have tohave, you get them and you get me an answer."
Okay. So what's he done? He's narrowed the
problem considerably. He has articulated the views
that had already been gathered pro and con on thisquestion and he has said to them very forceful,"This is the nub; get me the answer on the nub."*

Stello relayed the results of his efforts to Chairman Hendrie, who was convinced that Stello wasright. With the bubble concern alleviated, the NRC
did not recommend evacuation. Meanwhile, estimates of the bubble size continued to go down. At
8:21 p.m., the volume was calculated to be only 240
cubic feet.

any of the NRC personnel considered it dangerous
for President Carter to visit the site.
NRC Activities at the Site

As Sunday came to a close, the control of NRC
activity was even more vested in the NRC staff at
the site. On Sunday morning, Denton had decided
to open a full press center in the Middletown Borough Hall. There, from the stage overlooking the
gymnasium floor, Denton gave his daily press
conferences. At the site, NRC personnel had set up
a headquarters on Friday in a collection of trailers
adjacent to the observation center, in the area thatwas called Trailer City. NRC even had a small press
trailer at the entrance to Trailer City. Hendrie returned to Washington, but Mattson stayed on at thesite to further reinforce the NRC presence there.
NRC Contacts with Other Government
Organizations

Harold Denton continued to provide frequent
status reports to Governor Thornburgh throughout
the day.
Back in Washington, NRC consulted with HEW
officials concerning possible evacuation plans incase conditions at the reactor should seriously worsen. This was done in connection with an evacuation options paper that NRC was preparing at therequest of the White House. Work on this paper
had been initiated by Commissioner Gilinsky on Saturday night and was completed by a team headed
by Dr. Stephen Hanauer. It was decided that Chairman Hendrie would take the completed document tothe site and give it, with explanation, to Governor
Thornburgh. This document, entitled NRC Procedures for Decision to Recommend Evacuation, is
contained in Appendix 111.5.
As on Saturday, NRC gave periodic status reports to Congressmen, Federal agencies, and State
governments.

NRC Interaction with Met Ed

The close problem-solving, working relationshipthat was established between Met Ed and NRC on
Saturday continued on Sunday. The role of Met Ed
continued to be one of describing proposed operations and that of NRC was reviewing, evaluating,questioning, and approving them.
Communications between the NRC onsite staff
was still somewhat of a problem. In an early morni ng call, Denton asked Headquarters to have Stello's
people who were on site to call him at the site.
Moreover, Boyce Grier called occasionally during
the day asking Headquarters for reports on the latest developments.
Visit by President Carter

At 2:09 a.m., Harold Denton called Edson Case
for a briefing in order to prepare for an 8:00 a.m.
visit by President Carter to the site. Denton expected to be the principal spokesman, but he urged
Hendrie to come to the site to "show the flag."
Denton and the Governor accompanied thePresidental party, which included the President, Mrs.
Carter, and Jack Watson, Assistant to the President
for Intergovernmental Affairs, during the visit to thesite. Denton had given President Carter a complete
briefing on developments at the plant and an assessment of current conditions upon his arrival at
the Harrisburg airport. We found no evidence thatf. The Aftermath
Persistent degassing finally removed the gas
bubble sometime Sunday or Monday. There wasmuch debate about whether and when the bubble
was gone. Later, BMW showed calculations andnoise monitor traces which agreed that the bubble
was gone by 3:00 p.m. on Sunday, April 1. The NRC
acknowledged it had gone on Tuesday, April 3.

96 8

During the first week of April, there were many
discussions of when the Governor should lift his advisory for the evacuation of pregnant women andpreschool children. Early that week, lifting the advisory became tied to getting the plant to cold shutdown. There is no clear definition of what cold
shutdown is, and final cooldown depended on thetedious process of reviewing and then installing therevised cooling method. Finally, on Monday, April 9,long after the low level releases had stopped, theadvisory was lifted on the advice of the Commissionand Harold Denton.
From the time of its arrival on Friday, Denton's
team had been concerned about the technicalstrength of the Met Ed personnel onsite. Denton
and others periodically discussed with Met Ed andGPU officials the need for additional technical support, initially from safety systems suppliers like B&W
and later from other utilities such as Duke Power
Company 1 70 Calls for assistance were made to
suppliers and utilities. Denton also spoke to the
President, then to other White House officials about
the need for further support from industry. 171
Perhaps because of the efforts of Denton's teamand the White House, or perhaps because industry
groups already had recognized the need to help atThree Mile Island, outside technical assistance began to arrive over the weekend. An industry advisory group was then formed at the site to assist
Met Ed in making decisions.
The large NRC force on site worked closely withthe owners and the industry advisory group to workout an acceptable way to cool the plant down
without using the decay heat removal system in theauxiliary building. This method, based on the technique used for cooldown of naval reactors, would
use cold water circulation through the steam side of
the steam generators. Under close NRC review, thenecessary changes were made to install this system, but it was not turned on. Instead, it was held
as a backup system. Circulation pumped throughand around the core with slow steaming on thesecondary side of the steam generator continued tobe the method for heat removal. On April 27, 1979,
the operating reactor coolant pump was turned off,
and the TMI-2 reactor went on natural circulation
with the core heat removed by natural convection
flow of the coolant from the core to the steam generator. As of this writing at the end of December
1979, the same cooling method is being employed.
On April 17, after 19 days at the site, Harold Denton returned to Washington. On May 18, after 40days at the site, Victor Stello returned. However, alarge number of NRC staff remained at the site, andare still there today, evaluating and approving thecleanup and decontamination activities undertaken
by Met Ed.
3. EVALUATION OF THE NRC EMERGENCYRESPONSE
a. Management of the NRC Emergency
Response-Analysis and Findings
This subsection of the report discusses in detailour evaluation of the management of the NRC's
general response to the TMI-2 accident during thefirst 5 days of the emergency. Findings on specificmatters considered in the evaluation are listed at theend of this subsection.
Notification Procedures

The Region I procedure for receiving prompt notification of an accident proved to be ineffective
when it was used Wednesday morning, March 28.
At that time, the procedure for handling emergency
telephone calls during hours when the Region I office was closed was to have an answering service
call the Region I duty officer at home or wherever hemight be. The duty officer was required to carry anelectronic signal device ("beeper") that could be activated by the answering service. When he received
a signal from this "beeper," he was to call theanswering service as quickly as possible. The
answering service received the 7:10 a.m. call fromMet Ed but was unable to reach the duty officer forthat day, James Devlin. The NRC did not learn of
the accident until about 35 minutes later when somestaff members arrived at the Region I office to start
their normal work day and the Region I switchboard
opened.
NRC's Response Organizations at the Three Mile
Island Site
Initial Region I Team

Most of the group initially sent to Three Mile Island as members of the onsite inspection teaml acked substantial previous experience with the
TMI-2 plant. Of the first seven team members sent
to the site, only Karl Plumlee had substantial previous experience with or detailed knowledge of theplant. Plumlee had previously served as the principal or lead health physics inspector for the TMI facility. The other six team members had limited prior

96 9

experience and knowledge of the TMI plant. The
team lacked sufficient detailed knowledge of theplant to be able to observe, evaluate, and report on
the plant status and activities in a sufficiently effective manner immediately upon arriving at the site.
The Region I Incident Response Plan states thatusually the project inspector will be sent to the site
as the team leader. However, Donald Haverkamp,
who was the project inspector for TMI-1 and TMI-2,
and who had substantial experience with and detailed knowledge of the plant was not sent to thesite until the second day of the incident. He was
assigned to work in the Region I Incident Response
Center as a communicator on Wednesday and partof Thursday. Haverkamp should have been sent tothe site on Wednesday morning.
William Lazarus, the alternate project inspector
for TMI-1 and TMI-2, as listed in the Region 1Incident Response Plan, informed us in an interview 172
that he was not very familiar with either of the twounits. He told us that he had visited the TMI-2 plant
only once-and that was a familiarization visit at thetime he was assigned as alternate, about 2 years
ago. He also told us that he had inspected TMI-1 asa specialist inspector before that time. Lazarus did
not go to the site but was instead assigned to work
i n the Region I Incident Response Center. Assignment of a person without detailed knowledge of aplant to serve as alternate project inspector was aserious defect in the region's emergency response
capability.
The plan also states that the regional director
and deputy director will provide overall guidanceand direction to the onsite inspection team assessment and, as appropriate, go to the accident scene.
Neither of them went to the site on Wednesday or
Thursday. Either the Director, Boyce Grier, or his
deputy, James Allan, should have gone to the siteon Wednesday to supervise the NRC's response
activities and interact with Met Ed management at
the site. NRC Headquarters was remiss in notdirecting Grier or his deputy to go to the site assoon as the magnitude of the accident was recognized.
During depositions, some of the onsite inspection
team members indicated that they were given few
or no instructions by Region I management
173 as towhat to do when they arrived at the plant.
There
was and still is some confusion about who the teaml eader was. George Smith, branch
174 chief responsible
for radiological matters, testified
that he designated Donald Neely as the
175 team leader. Boyce Grieri ndicated in testimony
and in conversations taped
176
i n the Headquarters Incident Response Center
that he thought Charles Gallina was the team leader.
97 0James Higgins, one of the team members, indicatedthat he did not know who was assigned to be theteam leader and was not sure who was supervisorof his activities at Three Mile Island. 177 The onsite
i nspection team was not adequately instructed.
They did not know who the team leader was (theRegion I management was also not informed of who
the team leader was), what they should do when
they arrived, what they should look for, what theyshould report, to whom they should report, fromwhom they would receive instructions, and withwhom in the licensee's organization they shouldwork.
I n addition to the fact that the initial group of inspectors sent to the site lacked familiarity with the
TMI plant, and lacked adequate instructions, thenumber of staff sent was insufficient to gather andcommunicate to the region and Headquarters thelarge amount of information that was needed earlyi n the emergency.
Furthermore, the inspection team was inadequately equipped when it departed for the site from
Region I. The station wagon did not contain a radiotelephone over which the team could discuss theevolving situation at Three Mile Island with the Region I Incident Response Center. If the site had
been hours further from Region I, the radiotelephonewould have been even more important. The teammembers did not have battery-powered air sampling
devices (they had air samplers that required an alternating current power supply) so they could nottake air samples in the field, and they did not have
respiratory protective face masks for use in radioactive atmospheres.
The region's mobile laboratory was dispatchedalmost immediately to Three Mile Island from its location at the Millstone Nuclear Plant, but required 8hours to travel to the TMI site. Shortly after it arrived at the site, one of the tires was found to be flat
and another badly worn. The van was consideredby the inspection team members to be unfit for rovi ng environmental field survey activities. 178 Equipment needed for independent measurements by
NRC inspectors at the scene of an accident should
be available to them immediately upon their arrival at
the site.
Vollmer's Team from Headquarters

From the information we received, the role of theteam from Headquarters headed by Richard Vollmer
was unclear when the team went to the site on
Thursday following the accident. Apparently theteam was given unclear instructions as to what it
was to do or how it was to coordinate what it did

with Met Ed and the inspection team that was already at the site. Vollmer recalled in an interview
179(a) it waswith the Special Inquiry Group that:
Victor Stello who asked him to get people together
to go to the site; (b) his mission or role was "sort ofopen"; (c) Stello and "we all" felt that there was alack of adequate communication between the site
and the groups that needed to know what was goi ng on; (d) he was not told that his group would assist in recovery; and (e) "we went up without a real
definitive charter in my view, but one of trying to establish communication and understand what wasgoing on and reconstruct the sequences of prior in[sic] the past day so that we could perhaps understand what might best be done in the next few
days."
Transcriptsof theHeadquarters Incident
Response Center tapes show that about 3:00 p.m.
on Wednesday afternoon, Edson Case called Vollmer and told him:

staff at the site sufficiently to allow it to do morethan retrieve data.
The proper place for the principal NRC evaluatorsand decisionmakers to be following an accident is at
the site. In deposition, Denton and Stello echoed
this opinion. The flow of requests should be fromthe site to Headquarters, rather than vice versa as
was the case during the TMI accident until the Denton team arrived at the site. Headquarters should
provide technical support as needed and requestedby the principal team of investigators and evaluators
l ocated at the site. As noted previously, NRC Headquarters management was remiss in not sending
appropriate management staff to the site on
Wednesday, especially when there were such poor
communications and such real concern about theeffectiveness of Met Ed's action.
Headquarters Incident Response Center

The Headquarters Incident Response Plan
worked well as a procedure for the Office of Inspection and Enforcement to activate the Headquarters
Incident Response Center, staff it with an initial poolof IE personnel, establish communications links withthe region, and provide required notifications to other Federal agencies. It did not, however, sufficiently
address what happens when two or more separate
staffs, such as NRR and IE, must work together inthe Headquarters Incident Response Center. There
was no prepared plan that explained or specified
how the IE and NRR members of the Incident
Response Action Coordination Team (IRACT) andtheir support 182
staffs would interact or coordinate with
one another.
The procedure that evolved was
one wherein the IE IRACT members and support
staff served principally as coordinators for communications and data gathering, and the NRR IRACT
members and support staff served as analyzers andevaluators.
I n addition, there was insufficient coordination in
the Headquarters IRACT between the people working on radiological matters and those working on
operational matters. There was also insufficient
coordination of information between the IRACT andthe EMT and among the EMT members. For instance, in a deposition, Edson Case informed usthat he was not aware that Stello was concerned on
Wednesday about superheated steam or that the183
The generalcore was uncovered at that time.
practice evolved wherein members of the EMT, theIRACT, and the support staff worked and communicated with one another principally along their normal
office organizational lines. This was one of the principal causes of the poor coordination and communi-

The Commission wants us to start setting up a
post-accident and licensee monitoring team .... I
think you ought to be the man to head it up. There
will be tight liaison with IE [Office of Inspection and
Enforcement] and probably-maybe a couple of IE
guys on the team .... They're presumably going towind up with the containment building with water in
i t, contaminated to some degree.... And there will
be presumably changes needed in text specs [sic].
RemembertheBrownsFerry
situation
where ... your normal text specs [sic] just don't
cover this kind of a situation.... And you'll have towork on that, and those kind of things.... I don't
know when you'll be going up there but I would=i magine it would be shortly within a day or so.

Different members of the Executive Management
Team (EMT) have subsequently expressed different
views of what the Headquarters team role was tobe. 181 In any event, after Vollmer arrived, there wasno clear understanding on site as to who was incharge of the NRC onsite operations. In fact, Vollmer set up an organizational structure that was
separate from that of the region's onsite team.
Denton's Team from Headquarters

Asked by the President on Friday morning tosend a responsible senior official to the site to serveas the President's direct contact at the site and takecharge on behalf of the Federal Government, Chairman Hendrie asked Harold Denton to go immediatel y to the site. This was a proper course of action as
it put someone with authority to speak for the NRC
at the site. Also, Denton was accompanied by ateam of experts that increased the NRC technical
97 1

cations between NRR and IE that continued
throughout the incident.

why, with all its frustrations and concerns about
what action the licensee was taking, the EMT and
the IRACT did not make any attempt to contact Met
Ed management directly to find out what their plans
were and to propose matters they wanted
Met Ed185
to consider. Stello, in his deposition
stated that
he does not know why he did not contact Met Ed
management directly.
NRC Headquarters' failure to discuss its concerns with Higgins or have its concerns relayed tohim, and its failure to contact Met Ed management
directly on this subject shows poor judgment. NRC
management should have contacted Met Ed
management early on Wednesday and maintained
this contact at frequent intervals to discuss the actions that Met Ed was planning and to offer any advice or recommendations it felt necessary.

Headquarters Communications with NRC Staff at
Region I and the TMI Site

The physical communication systems (e.g., telephone lines) used by Headquarters to communicate
between the site and the Region I and Headquarters
Incident Response Centers and among the onsite
inspection team members were unreliable andinadequate. In addition, poor framing of requests for
information by Headquarters, and requests for many
individual bits of data that saturated the communications system prevented the onsite team from effectively providing the information that was most needed early in the accident. In requesting informationfrom the region and the onsite team, Headquarters
failed to explain in general terms what it considered
to be the problems it was trying to evaluate. Had
this been done, Headquarters would probably havegotten much better results. It would have also beeneasier for the staff at the site to answer questions if
Headquarters had attempted to group its questions
rather than asking them in the piecemeal mannerthat it did.
Communications problems were exacerbated fora time on Wednesday morning by the uncoordinateduse of separate telephone lines between Headquarters and the region for radiological and operational
information.

Headquarters Management Coordination with
Region Management

Coordination between the Headquarters management and the region management was poor. As
noted earlier, Headquarters management did not explain in general terms what it was trying to evaluate.
After Headquarters made its direct telephone linkup with the TMI-1 control room and subsequently
with the TMI-2 control room, the region was largely
bypassed by Headquarters in the direction of theonsite team with respect to operational matters.
Through Sunday, the region was not informed ofmany of the matters that were of concern to Headquarters or of actions that Headquarters was planning. Because it was not consulted or informed, theregion was not able to plan its activities as well as itshould have. This lack of coordination with Region I
management probably contributed to the difficulties
that Headquarters was having in acquiring operational information on Wednesday and Thursday.
This problem continued through Sunday inasmuch
as the region management was not informed by
Headquarters of the preparation of evacuation contingency plans over Saturday night and Sunday
morning. Boyce Grier, Director of Region I, who
was at the site, did not learn of this until he called
John Davis at about 11:00 a.m. on Sunday to suggest that such planning be done.

Headquarters Coordination with Met Ed

There was no interaction between Headquarters
management and Met Ed management until Denton
was sent to the site on Friday. The discussion on
Wednesday afternoon between Headquarters and a
Met Ed TMI-1 shift supervisor, Greg Hitz, concerningsuperheated steam in the reactor vessel and the indications that the core was uncovered apparently
never resulted in consideration of the issue by Met
Ed plant management. We do not understand why
Headquarters did not explain this concern to James
Higgins, the NRC reactor inspector who was stationed inside the TMI-2 control room. Higgins stated in his deposition with the Special Inquiry
Group' 84 that he did not hear any discussions of
this subject by Met Ed management located in the
TMI-2 control room. Higgins also stated that if hehad been informed of the Headquarters IRACT'sconcern, he was in a good position to and would
have made sure that Met Ed management considered the matter. We also do not understand

Grier: Yeah somebody down there ought to bel ooking at the situation continuously as to whatmight happen ... and how much time we have got.
Davis: Now I understand that's being done. Now
you don't have all that information up there.
Grier: No and I don't know where to get it.

97 2

Commission Involvement in the Response

override the staff's earlier recommendation to theState to evacuate the surrounding area. When
Governor Thornburgh asked Hendrie whether or not
Harold Collins of NRC was correct in earlier recommending to the State that it evacuate, Hendrie told
the Governor that he would check on it, but he never got back to the Governor on this subject and still
could not respond when the Governor asked him
again on Sunday. 189 We believe that this was oneof several incidents where poor coordination andpoor communications within the NRC fueled distrustof the NRC by State officials. In a similar instance,
Hendrie could not confirm to the Governor that Galli na was NRC's contact man at the site. 190
On Friday night, Hendrie personally asked thestaff at the Headquarters Incident Response Centerto consider the possibility that the hydrogen andoxygen concentrations in the reactor vessel mightat some time reach proportions at which they might
explode. This concern had not occurred to thestaff. Headquarters diligently pursued this subject,
getting assistance from a number of experts outside
the NRC. The NRC staff at the site believed there
could be no free oxygen present and hence no explosion. When Roger Mattson and Hendrie went tothe site on Sunday with their estimates on the explosion potential, the NRC staff at the site convinced
them that no explosion could occur. Headquarters
apparently had failed to coordinate its efforts with
the NRC staff at the site, with the result that until
they went to the site on Sunday, Mattson and Hendrie believed the oxygen concentration could build
up inside the reactor vessel to a level at which detonation of the hydrogen could occur.
As noted in the narrative, Commissioner Gilinsky,
in response to a White House request, asked thestaff on Saturday night to develop an emergency
contingency plan. We believe that the EMT or
Commission should have directed earlier that a contingency plan be developed. It seems that the WhiteHouse made an important request for an action that
the Commission or EMT should have been taking already.
It was a mistake for the Commission to interject
itself only partially into the management of the NRC
response. It should have either made it clear to thestaff that it was assuming command of the NRC
response or made it clear that the EMT was in complete command. The fact that it interjected itself
partially caused some confusion among EMT
members. Although none of the EMT members
have told us so, we believe that the confusion led
some of them to rely on the Commission for decisions or to assume that Commission approval was

At the time of the TMI accident, there was no
specified role for the Commissioners in a nuclear
emergency. Notwithstanding this lack of definedrole in an emergency response, the Commission interjected itself into the agency's response activities
on Wednesday and assumed an increasingly activerole with each ensuing day through Sunday, April 1,
1979. On the first day of the accident, most of theCommissioners limited their activities to staying informed of the developments either from their offices
i n Washington, D.C., or through personal visits to
the Headquarters Incident Response Center in
Bethesda, Md. However, Commissioner Gilinsky,
who was Acting Chairman due to Chairman
Hendrie's absence from the office on Wednesday
morning, took a visibly active role that included suggesting to the EMT that it assign someone to think
about what to do with the radioactive water inside
the containment; 187 requesting the EMT to ensurethat measurement information from the NRC, theDepartmentla8
of Energy (DOE), and the State werecoordinated;
contacting the White House; andcommunicating with the Pennsylvania Governor's
office.
The Commission's role in directing the EMT activities, and its involvement in the accident response
escalated daily. On Thursday, Chairman Hendrie involved himself in the staff's activities concerningsurveillance of industrial water releases and was instrumental in promulgating an NRC order to the utility to stop a release of industrial wastewater. The
order seemed to be motivated principally by a concern for public reaction to the releases and an apparent EMT lack of information about the releases.
It appears that, in response to the chairman's concern, the EMT asked the IRACT to order the plant tostop the releases. The IRACT, without considering
the region's reasons for continuing the dumping or
discussing these reasons with the EMT, orderedthat the region order the plant to stop dumping.
The handling of the industrial waste releases on
Thursday and the EMT's failure, as discussed
below, to check with the site before recommending
evacuation on Friday morning illustrate serious
failures of Headquarters officials to establish thefacts surrounding an issue before making decisions
and issuing orders.
Discussions of evacuation on Friday morning
forced still greater involvement of the Commission in
directing the NRC's response activities when theCommission assumed management of the NRC's
evacuation-related activities. Its first action was to97 3

required before they acted on substantive issues;other EMT members did not appear to believe theyrequired Commission approval.

When NRC Headquarters first notified the DOE of
the accident Wednesday morning, March 28, it
alerted DOE that aerial surveillance support might
be needed but then delayed making the request forassistance until almost 11:00 a.m. As a result, therequested DOE aerial surveillance did not arrive at
the site until about 1:30 p.m. We believe that DOE
aerial surveillance support should have been requested during the first call. A general emergency,
i nvolving extremely high levels of gaseous radioactivity in the reactor containment building and uncertain plant status, as existed in the TMI-2 accident, in
our opinion, called for more than an alert. DOE aerial surveillance should have been requested immediately.
The Pennsylvania Bureau of Radiation Protection
requested monitoring assistance from the DOE Radiological Assistance Team (RAT) at BrookhavenLaboratory. Met Ed, the NRC, the State, the DOE
Aerial Measurement System/Nuclear Emergency
Search Team from Andrews Air Force Base, andthe Brookhaven RAT were all monitoring the radiation doses and gathering radiological data in thearea surrounding the plant.
As noted previously, Commissioner Gilinsky requested the EMT on Wednesday to ensure thatmeasurement information from the NRC, DOE, andthe State were coordinated. Notwithstanding thisrequest, there were coordination problems during
the first few days. The NRC had difficulty obtainingsome of the ground measurements that the
Brookhaven RAT had made. The Brookhaven RAT
would only give its data to the State, apparently because the State had requested its assistance. In
addition, some of the other Federal agencies wereexpressing the view that they were not appropriatel y informed or involved in the activity. These probl ems were discussed at an interagency meeting heldat the DOE site headquarters at the Capital City Airport on Friday night. At that meeting, the DOE was
assigned to coordinate all of the data.

State, Congressional, and Federal officials and tothe media. In many instances, these designatedspokesmen were actively involved in responding to
the emergency, and the time they spent acting as
spokesmen impaired the agency's emergency
response effort. The agency failed to anticipate theneed for these spokesmen and to specifically assign
officials who were not actively involved in respondi ng to the emergency to perform those duties. Pulli ng the onsite inspectors, Gallina and Higgins, awayfrom the plant on Wednesday evening and again on
Thursday afternoon to brief the Pennsylvania
Governor and Lieutenant Governor and to participate in press conferences, diminished the effectiveness of the NRC in assessing the situation and reporting plant status and other information to the region and to Headquarters. On Thursday, key NRC
staff members were pulled away from their jobs associated with the NRC's response to the accident tobrief a congressional committee in Washington,
D.C., and to brief two separate congressionalgroups that went to the Three Mile Island site to observe firsthand what was happening. On Friday,
Harold Denton was sent to the site to manage theagency's response and to serve as the agency
spokesman there. Instead of actively managing theactivities, it turned out that he had to spend much of
his time in briefings.
I n all, hundreds of personal conversations were
held with government officials to keep them informed of developments throughout the accident.
This required a great deal of effort by NRC's top
management staff. Although some effort was madeby the NRC to prerecord information, the recorded
i nformation was not kept current and consequently
was of little value to callers.
I n addition to telephone calls and personal briefi ngs, NRC used preliminary notification documents
prepared by NRC's Office of Inspection and Enforcement to keep people informed. A reading ofthese documents concerning the TMI accident,
which were used to inform other governmental offices, reveals that these documents may not havebeen fully understandable to the lay reader. The
NRC needs to improve the understandability of preli minary notification documents by using nontechnical terms to the greatest extent possible and by explaining the significance of all reported information.

I nforming the State, Congress, Other Federal
Agencies, and the MediaThe Role the NRC Should Take in Emergency
Response

Coordination with Federal and State Agencies
Responding to the Accident

Throughout the accident, senior NRC officials at
Headquarters and at the site who were most familiar
with the facts were selected to act as spokesmen to

The Commisson's stated policy with respect toemergency response indicated that the NRC would
evaluate the adequacy of the licensee's actions in974

i n close coordination with the licensee's technicaland management staff to gather information, evaluate the situation, recommend possible actions tolicensee management, review and approve needed
license changes, and review and concur in proposed major licensee actions. This is essentiallythe role the NRC exercised at Three Mile Island
after the Denton team went to the site. We also envision that the NRC will intervene at times to countermand some order by the plant management or togive some order regarding plant emergency operations.
We believe the NRC's present legal authority is
sufficient for such on-the-spot orders (see Appendix 111.1), but we believe it would be useful to clarify
this, at least with public dialogue in emergency planning, preferably with clearer statutory authority as
well.

response to an accident and, if necessary, could intervene to direct the licensee's actions. However,there was no specific guidance or planning to ensure adequate sources of data from which to makesuch assessments, to ensure careful integration of
the various elements of evaluation to provide acomprehensive overall assessment, or to ensure
coordination of NRC assessments with those of theli censee's technical staff to determine the nature ofand adequacy of ongoing and planned actions by
the licensee. Thus, the broad "objectives" of the
NRC policy had no preplanned substance. We beli eve this lack of planning and uncertainty about theagency's role in emergency response pervaded the
NRC's actions in the TMI emergency. The difficulty
was intensified by confusion about the respectiveroles of the staff members and the Commission.
As part of this inquiry, we have considered what
the role of the NRC should be in an emergency. In
addition, we contracted with the National Academyof Public Administration (NAPA) to study alternatives
for government action in nuclear crisis management.
NAPA used a panel of experts with a broad spectrum of government experience to advise and direct
the NAPA staff. The products of the NAPA work
are a staff report and a panel report. They are publi shed together as NUREG/CR-1225. The NAPA
panel report and a list of the panelists is in Appendix 111.6. We find that the NAPA recommendations
are generally consistent with our own about theproper role of the principal parties in a nuclear emergency.

Evaluating Licensee Operation of Plant
During the first few days following the TMI accident, the NRC managed its response from Headquarters in Bethesda, Md. It used its onsite team ofi nspectors principally as data gatherers and performed all its evaluations at Headquarters. Due topoor communications channels between Headquarters and the site, poor framing of questions by
Headquarters, and poor coordination of information
within the Headquarters Incident Response Center,the management of the response was ineffective.
Headquarters did not feel that it had sufficientknowledge of what was going on at the site to accurately evaluate the situation and give orders to
the licensee when it was concerned about the core
being uncovered on Wednesday. And on Friday
morning, when Headquarters did take a positive action and recommended evacuation to the State, it
did so on the basis of an inaccurate understandingof what was happening at the site. Although the
NRC team at the site on Wednesday and Thursday
was better informed about what was happening at
the plant than Headquarters, the team was not sufficient in size or technical expertise to effectively
evaluate the complex situation at the plant.
When Denton's team went to the site on Friday,
the NRC had, for the first time, a staff at the site
sufficient in number and technical expertise to effectively monitor and evaluate the situation. It also
had the authority to approve license changes and toorder the licensee to take or to stop actions as itsaw fit. Denton was the authorized and recognizedspokesman for the agency with respect to the accident and as such was able to work effectively withOperating the Plant

Even before the TMI accident, the NRC requiredthat an operator undergo extensive training anddemonstration of qualifications before being authori zed to operate a nuclear plant. After the TMI accident, it is obvious that even more operator expertise is required. With this in mind, we do not consider it reasonable that NRC maintain a separate
staff of operators, prepared to step in to take over
the operation of any afflicted plant. The number ofexpert operators needed would be very large; theywould have to be unusually expert to step in during
an accident; and the boredom of their ordinary
work, waiting for an accident, would be a serious
problem.
Realism prompts us to recommend that the NRC
not take over the plant in a crisis, but the NRC does
have a continuing obligation to monitor closely the
emergency response of the operators and to exert
what regulatory authority is necessary to protect
the public. To do this, we envision the NRC working
97 5the Met Ed management and with Governor Thornburgh.
Management of the agency's response from
Headquarters was not effective following the TMI
accident, but management of the response from thesite, after Denton's arrival, was effective. We believe that the NRC should send an emergency
response team sufficient in size, technical expertise,and management capability to the site of an accident, and move the management of its emergency
response to the site as soon as possible following
the accident. Headquarters should provide technical assistance as requested by the response teamat the site.
We believe that with careful preselection of personnel and adequate training, the team sent to thesite can be drawn from the regional office. It shouldbe headed by the regional office director or his
deputy whenever possible. The director is wellknown to the plant operators and to many local authorities as the principal NRC manager responsible
for the plant. Through careful advance endorsement, he can be identified as the chief NRC spokesman on the scene. The director can draw from his
own office the technical expertise he needs for thej ob at the site. Where necessary, specialists might
be drawn from other locations. Working principallyout of the regional office, the site team can develop
and refine its procedures and equipment and evendrill in conjunction with its normal activities.
However, as long as the regional office is an IE
office without licensing authority of its own, it will bedifficult for the regional office director to give orders
to the operators when necessary. Therefore, the
NRC should delegate to the site team director in advance plenary authority for all agency actions withrespect to the emergency. The delegation of thisauthority should be carefully explained to the operators and to State and local officials in advance. No
governor should ever have to ask for the credentialsof the NRC spokesman.
We considered the alternative of having the
emergency response team to the site drawn principally from Headquarters rather than from the regional office. We rejected this alternative for four
principal reasons. First, the Headquarters staff has
far less day-to-day familiarity with the facility andlocal officials involved. A Headquarters staff cannot
possibly hope to develop complete familiarity withevery facility and every critical official throughout
the United States. Second, the regional office istypically closer to the facility and should be able toreach it sooner. Third, the regional office is alreadyequipped for supplementary radiological monitoringand its staff is practiced in the use of this equipment. Fourth, if Headquarters staff took the lead in

the onsite team, they would almost certainly have toalso include a substantial number of regional officepeople. One dramatic lesson of the accident atThree Mile Island is that emergency response teammembers, whether at the site or in Bethesda, tend
to work in their regular chain of command. Special
emergency chains of command, superimposed on atemporary group, are likely to cause great difficulties.
We recognize, of course, that the present regional office staffs may need reinforcement and training
to be able to meet this emergency responsibility.
But that, we submit, is preferable to trying to createa "special" team at Headquarters ready to fly anywhere in the country at a moment's notice. It may
be perfectly appropriate to have technical speciali sts and public information assistants from Headquarters trained and ready to be called upon in an
emergency. However, the region's onsite team, not
Headquarters, should have responsibility for decidi ng what support to request so that these additional
specialists and assistants enhance rather than diminish the onsite team's effectiveness.
The region's team may need at least several
hours to reach the site, even with careful planning.
I n the meantime, the Headquarters duty officer, andthen the IE director or his designee, when he arrives
at the Headquarters Incident Response Center,should be the sole spokesman, responsible for
NRC's recommendations and response actions andvested with all agency authority regarding the accident situation. We believe that to serve in thiscapacity, a person so remote as one at NRC Headquarters should be provided with directly transmitted plant and environmental information sufficient toassess the situation. A separate study should bemade promptly to identify plant parameters, equipment status, and environmental information thatshould be transmitted to Headquarters on callwhenever a plant has a serious emergency. We do
not consider it practical for high-level officials of the
NRC such as the chairman or office directors toserve as Headquarters duty officers. The responsibili ty for NRC emergency actions should be given totechnically competent intermediate level managers
who are assigned as duty officers and then to the IE
director or his designee, and left with them except
for the transfer of lead responsibility from Headquarters to the site team when the team director
has arrived. We believe it would be reasonable for
the NRC site team director to work from a central
emergency response center close to the site provided that it has at least as much data directly available to it as we expect to be available to NRC
Headquarters, and provided that the site teamworks directly at the site to the degree necessary.
97 6

Findings
1.
2.

3.

4.

5.

6.

7.

8.

The Region I system for receiving prompt notification of an accident proved to be ineffective when it was used Wednesday morning.
Most of the group initially sent to Three MileI sland as members of the onsite inspection
team lacked substantial previous experience
with the TMI-2 plant and lacked sufficient detailed knowledge of the plant to observe,
evaluate, and report on the plant status andactivities in an effective manner immediately
upon arriving at the site.
It was a mistake that Donald Haverkamp, the
NRC project inspector for TMI-1 and TMI-2,
was not sent to the site on Wednesday morning, and that Boyce Grier or his deputy did not
go to the site on Wednesday to supervise the
NRC's activities and interact with Met Ed
management at the site. Headquarters wasremiss in not directing Grier or his deputy to
go to the site as soon as the magnitude of theaccident was recognized.
Assignment of an individual without training
and experience with the TMI plants to serveas the alternate project inspector was a serious defect in the region's emergency
response capability.
The onsite inspection team was not adequatel y informed as to who the team leader was(the Region I management also was not informed of this), what they should do when
they arrived, what they should look for, what
they should report, to whom they should report, from whom they would receive information, and with whom in the licensee's organization they should work.
The onsite inspection team was inadequately
equipped when it departed for the site from
Region I. Equipment needed by the NRC inspectors for independent measurements atthe scene of the accident was not available tothem immediately upon their arrival at the site.
There was no prepared plan that explained or
specified how the IE and NRR members of
I RACT and the IRACT support staff would interact or coordinate with one another.
I n the absence of prepared plans, IE and NRR
staff members who were part of the EMT,I RACT, and IRACT support staff at Headquarters tended to function along organizationalli nes, each individual dealing most frequently
and effectively with those individuals withwhom he usually worked. This tendency also
was in evidence among members of theagency's onsite organization after Denton and

9.

10.

11.

12.

13.

14.

15.

16.

97 7

his team of technical experts arrived at thesite on Friday to supplement the work of personnel from Region I. There was insufficient
coordination in the Headquarters TRACT
between the people working on radiologicalmatters and those working on operational
matters, between the TRACT and the EMT, andamong EMT members.
The physical communication systems (e.g.,
telephone li nes) used to communicate
between the site and the region and Headquarters response centers and among onsite
i nspection team members were unreliable andinadequate.
Poor framing of requests for information by
Headquarters and requests for many individual
bits of data saturated the communications
system and prevented the onsite team from
effectively providing the information that wasmost needed early in the accident.
When Headquarters asked for information, it
did not explain adequately in general terms to
the region or the onsite team the problems it
was trying to evaluate.
An insufficient number of staff members weresent initially to the site on Wednesday morning
to respond to the almost continuous flow ofi nformation requests from Headquarters. NRC
personnel on site did not have a single command center at Three Mile Island, which increased the difficulty of ensuring a coordinated response by onsite personnel.
The NRC did not have one individual on sitewith the competence and authority necessary
to give essential orders until Harold Denton
was well established at the site.
When the Denton team went to the site on Friday, the NRC had, for the first time, a staff at
the site sufficient in number and technical expertise to effectively monitor and evaluate thesituation. It also had the authority to approve
license changes and to order the licensee totake or to stop actions as it saw fit. Denton
was the authorized and recognized spokesman for the agency with respect to the accident and as such was able to work effectively with the Met Ed management and with
Governor Thornburgh.
Management of the agency's response from
Headquarters was not effective following the
TMI accident, but management of the
response from the site, as was done after
Denton's arrival, was effective.
NRC coordination with Met Ed was deficient inthat NRC management did not contact Met Ed
management early on March 28, 1979, and

17.

18.
19.

20.

21.

22.
23.

24.

25.

to protect the public from the consequences of a
nuclear accident. Therefore we present our evaluation of this important aspect of the NRC's response
separately.
When the NRC was first notified of the TMI emergency at 7:45 a.m. on March 28, 1979, the plant
operators had already established close contact
with the Pennsylvania Bureau of Radiation Protection (BRP). Met Ed was doing what it was required
to do by the emergency plan. The plan held thelicensee responsible for directly contacting theState radiological authorities to report the situationand to recommend evacuation or other protective
measures when necessary.
The plan did not assign a voice to the NRC in that
dialogue. There was no clear NRC policy that provided guidance concerning whether NRC shouldmake evacuation recommendations to State officials, under what conditions it should make them,
who should make them, and to which State officials
they should be addressed. In our investigation, we
found that the NRC inspection team, upon reaching
the site, verified that this channel between Met Ed
and the State was functioning for the reporting andevaluation of evacuation-related information. However, this plan like many others had a fundamental
flaw. It conditioned the participants to think of protective measures being taken only on the basis ofactual plant conditions and releases, not on thebasis of deterioration in the situation. Although radioactive releases were quite low on Wednesday,
there was great uncertainty about the ability of Met
Ed to control the cooldown of the plant and thereleases. This uncertainty should have been considered on Wednesday as a possible basis for evacuation. The NRC staff at the site and at the Region
I and NRC Headquarters failed to consider possible
offsite releases as a basis for evacuation; they obviously confined their attention to the measured
offsite dose rates. They should have made regularappraisals of the plant conditions or status and provided explicit advice to the local authorities basedon that appraisal.

maintain this contact at frequent intervals to
discuss the actions that Met Ed was planningto take, to make any recommendations it felt
necessary, and to bring any information or
thoughts it felt appropriate to Met Ed's attention.
Coordination between the Headquarters
management and the region management waspoor in that Boyce Grier was not kept informed of Headquarters' concerns about theplant or what Headquarters was planning todo.
The NRC staff and the Commission were uncertain of their roles in the TMI response.
As the accident progressed, the Commission,
most particularly Chairman Hendrie, took an
i ncreasingly active role in the management of
the NRC's emergency response despite thefact that the Commission had no specificallydefined role to play according to the agency's
emergency response planning documents.
It was a mistake for the Commission to interject itself partially into the management of the
NRC response without either making clear tothe staff that it was assuming command of the
NRC response or making it clear the extent towhich EMT was in command.
There was no NRC planning to perform acomprehensive assessment of the adequacyof the licensee's recovery action taken at theplant.
There was no NRC planning for NRC intervention to approve or to direct the licensee's actions in response to the accident.
The NRC's coordination with the DOE, with
the State, and with other Federal agencies,
was inadequate to ensure that needed data
was being developed and that the State, theDOE, the NRC, and other Federal agencies
were getting all of the information they needed.
Key members of the NRC technical staff were
pulled away from important emergency
response activities to brief State officials, theCongress, and the media.
NRC preliminary notification documents thatwere used as a basis for informing othergovernmental offices about the accident were
not sufficiently understandable to the layreader.

Who Speaks for the NRC?

From Wednesday evening through Thursday
afternoon, the situation remained essentially thesame, with onsite NRC personnel monitoring the"evacuation interface" between Met Ed and theState. However, starting Wednesday evening, theGovernor and Lieutenant Governor asked two of the
NRC inspectors, Charles Gallina and James Higgins,to report the plant status and the possible need forprotective measures. These inspectors were put inthe unenviable position of having to: (1) perform ab. Evacuation Issues-Analysis and Findings
The Three Mile Island experience showed that
the NRC was and will be deeply involved in actions
97 8

tion 1 94 At that meeting Karl Abraham, a public affairs officer, suggested consideration of more radiation sensitive people such as pregnant women. The
Governor has since related that he lost faith in thelocal NRC spokesmen when Gallina said to thepress after this meeting that the danger was overfor people offsite. 195 We believe the NRC was beginning to pay a price for leaving the burden of thisimportant task on the shoulders of relatively juniorpeople at the site without useful assistance. We
have found no evidence that the Governor related
this dissatisfaction to anyone at the NRC at thisti me.

major inspection effort at the site; (2) act as theprincipal channels for communicating information to
the NRC Region I and Headquarters offices; and (3)act as the NRC's spokesmen to the most senior local officials and the public. Gallina and Higgins werecalled to this last task Wednesday evening andagain on Thursday afternoon, with the knowledge
and concurrence of the NRC management.
The only evidence that the NRC management
conferred with these men before they had to meetwith the Governor and the press on either day wasan exhortation to Gallina before the first meetingfrom his regional office director that he "be open
and tell it like it was." 191 We believe that it waswrong to leave the responsibility for this high-levelcontact to these two individuals on both days, especially without consultation. We find it remarkablethat on Friday morning, after the name was given tohim by Governor Thornburgh, Chairman Hendrie
asked the IRC,
"Do we have a man named Gallina
192
down there?"Thus, when Gallina and Higgins
discussed evacuation matters with the Governor,
they had no benefit of higher level consultation.
On Thursday morning, Lt. Gov. Scranton asked
Commissioner Gilinsky whether the children in nearby Goldsboro should stay indoors as a radiologicalprotection measure. Gilinsky did not answer thequestion but had Harold Denton call Mark Knouse of
Scranton's office on the matter. Denton made whatmight be called a negative recommendation by explaining to Knouse why he felt protective measures
were not necessary.193 We found no evidence that
Denton was describing a previously reached negative recommendation. Denton's answer appears to
be an on-the-spot response to Scranton's question.
Denton's evaluation was consistent with theknowledge of the plant status at the time. It is interesting to note that the State authorities thereby
opened a new channel for evaluation and recommendations regarding protective action. They began with technical contact with Met Ed, added thecontact with Gallina and Higgins, and now opened
higher level contact at the Commission and officedirector level. There was an opportunity here for
the NRC management structure to decide whoshould be the evacuation spokesman to the State
officials and at what level the contact would be
made. That opportunity was missed and a great
deal of confusion occurred the very next day because of it.
On Thursday, many had heard that Dr. Ernest
Sternglass had recommended evacuation of pregnant women and small children from areas around
Three Mile Island. At the Thursday afternoon meeti ng of Gallina and Higgins with Governor Thornburgh, there was extensive discussion of evacua-

The Friday Morning Fiasco

The greatest problems with evacuation evaluation
and recommendations started Friday morning.
Through Thursday evening and the early hours of
Friday, the NRC was learning ominous things about
the condition of the plant. This information waschanneled to the EMT in the Incident Response
Center. The evaluation process was greatly perturbed by the fortuitous combination and coincidence of Lake Barrett's offsite dose rate estimate
with Karl Abraham's request from Harrisburg forverification of a reported over-the-plant dose ratemeasurement. The record shows that the EMT did
not evaluate the information in an orderly way, did
not reach a decision in an orderly way, and did noti dentify and follow a clear course of consequent action. In sum, the EMT evacuation decision madejust after 9:00 a.m. on Friday, March 30, was badon all counts: evaluation, decision, and action.
The analysis that produced a serious offsite dose
estimate was based on a recent (8:45196
a.m.) reportthat the waste gas tanks were full.
Althoughthere appeared to be serious ramifications of thischange in plant status, we found no record of any
attempt to verify it. Later inquiry has shown that thereport was erroneous; the tanks were not full.
The report of a 1200-mR/h gaseous release fromsomeplace "in one of the cooling towers" was obviously garbled because cooling towers don't emit radioactive gases, and was clearly tendered with a re197
quest for verification.
Both factors were sufficient reason to verify the report; the EMT did not.
The error was even compounded by treating thedose rate as if it represented an offsite ground leveldose. We believe these failures by the NRC are
dramatic examples of the need to verify facts thatare crucial to a major decision.
The EMT decision process was also faulty. The
EMT was a group under the direction of the NRC's
Executive Director for Operations, Lee Gossick.
The decision process as reported by Lake Bar97 9

rett198 does not reflect a clearly led group. Harold
Denton seems to have made a decision to recommend evacuation of the area around Three Mile Island. The actions that followed further confused thematter. Denton did not turn to Gossick, the EMT
director, to notify the State officials. Instead, Denton himself instructed Harold Collins of the NRC
State Programs office to transmit to the State thisgrave recommendation to evacuate. Collins choseto transmit the recommendation to Col. Oran
Henderson of the Pennsylvania
Emergency
Management Agency, and he did so in an uncertain
way, first asking 199
Henderson what they were told
about the release.
This EMT decision and action was defective inmany ways. The decision was not made throughthe designated decision structure. It was madeabruptly with little or no deliberation, although there
was nothing in the information at hand or this situation that suggested such precipitous action. A
sense of the confusion in this abrupt decision canbe gained from Denton's and Gossick's later recollections. Denton told us that he felt the EMT had toact because
the Commissioners were not readily
200
available.
Gossick told us that he turned to theCommission for this decision because they wereavailable. 201 The first phone call to a Commissioner( Bradford) was completed by Denton only 11 minutes
after Karl Abraham's call.
The NRC EMT, with its battery of telephones anddozens of staff assistants in Bethesda and at thesite, was not up to the evacuation decision. The illfounded recommendation to evacuate was challenged almost immediately because it did not matchthe situation at the site. The EMT turned to theCommission to affirm the recommendation. The
Commission had more authority but it certainly had
less information, relying almost entirely on information passed to it by the EMT. If the EMT's decision
to recommend evacuation had been a good one, we
believe that the Commission could and would haveaffirmed it promptly. But the EMT calls that brought
the matter to the attention of the Commission contained information that showed no need to evacuate.
It is difficult to fault the chairman for not affirming
the staff recommendation because of this.
From our investigation we believe that the Commissioners discussed the matter of protective action
advice collegially but there is no evidence that theCommission took any formal vote to reach a position. The chairman seems to have heard the viewsof the others and then acted in accordance with hisbest judgment. We believe the Commission acted
sensibly to depart from the voting process underthese circumstances. Chairman Hendrie had had
98 0extensive training and experience in the field of nuclear safety and was therefore capable of evaluating
the situation and making correct decisions andrecommendations. However, we would not expectthat every chairman would be as well qualified tomake the agency's decisions related to nuclear accidents. Therefore, we recommend that the Chairman of the Commission should not make decisionsof this sort for the agency during an emergency. A
cadre of qualified intermediate level managers
should be identified and trained for this decisionmaking role, and the agency should make clear to
all that the one on duty during an emergency will
speak with competence and full authority for the
NRC. Such a person would represent the peakcombination of technical competence, training, andauthority for the agency. We presume that higher
level authorities in the agency will be available usually and, of course, concerned about the situationand the agency's actions. If the responsibility isclearly held by the designated action manager thenno loss of effectiveness will come from periodic
consultations between this manager and higher levelauthorities as time permits. However, there must be
no expectation that this manager will clear his decisions with the higher authorities, or the agency will
be right back to the TMI difficulties. It should beclearly understood by local authorities and by other
Federal authorities (such as FEMA, EPA, DOE) that
this emergency duty officer speaks for the NRC.
The ultimate decision coming from the Friday
morning evacuation uproar was endorsement of anadvisory from the Governor that pregnant womenand preschool children leave the area of the plant.
We are unable to endorse this decision as a reasonable one except as a compromise for the false
alarms that preceded it. By the time of the advisorydecision, the release had stopped but could startagain and repeat periodically. It was known that
offsite dose rates were low, only occasionally goingup to 10 or 20 mR/h. At those dose rates, it would
take 50 to 100 hours of continuous exposure to
bring a sensitive person such as a pregnant woman
to the EPA Protective Action Guide level of 1000
mR. With the intermittent character of the releases,
the time required was much longer. However, it isdifficult to fault Governor Thornburgh and Chairman
Hendrie for it, because they were both confronted
with confusing information, and the situation wascomplicated by the actions of others-the EMT
recommendation of total evacuation and Kevin
Molloy's radio broadcast that the public should get
ready for an evacuation order.
The Governor and the Chairman would havebeen helped greatly if they had a simple decision-

of this problem would have reduced the concern
and been useful for identifying the most important
contingency plans needed.
The bubble concern began with fear of its volume
displacing cooling water in the core. Later on Friday it became fear that, if the operators could successfully vent the bubble to the containment atmosphere, it might add enough hydrogen to cause an
explosion. There was the additional concern that,once the plant vented into the building, radiolysis in
the core might generate still more hydrogen to add
to the problem. This concern led to the first estimates of the hydrogen, and oxygen, generation
rates. Later, when the concern shifted to flammability of the bubble still in the reactor system, we beli eve there was a natural tendency to carry overthese estimated radiolysis rates. As the NRC staff
pursued the evolving bubble concerns, staff
members from different parts of the agency weredrawn to work on it. Each group seemed to turn toa different outside consultant. The result was achaos of poorly related questions and answers. In
the carefully reconstructed chronology in Appendix
111. 4, one sees a confusing array of questions goingout and answers or opinions coming back in no pattern. Important opinions were not heard by the rightpeople. In one example of this, Warren Hazelton, an
NRC staff member of considerable expertise inreactor chemistry, was analyzing the metallurgicaleffects of all that hydrogen on the reactor vessel
steel. Hazelton heard that others were worried
about the oxygen generation rate and felt they were
neglecting the reverse reaction. Hazelton raised an
objection, but in the confusion he gave his opinion
to Robert203
Ritzman, a consultant working with another group.
It was as if the focal point for the issue
was this person outside the NRC staff. Later, Roger
Mattson told us, "Had I been aware that Hazelton
had an opinion, it probably would have caused me
to go to Hazelton, whom I know to have some physical chemistry capabilities and some metallurgicalcapabilities .... I might have talked to him directly
and grown to understand that he did haveknowledgein this field that could be relied
204
upon...."
Just as the Governor was forced todetermine the credentials of those who advised local officials to evacuate, Mattson was trying todetermine the credentials of consultants and advisors as the problem was being analyzed.
The most notable feature of all this is that the
NRC staff had no recognized group that had the expertise to answer questions of reactor chemistry.
We believe that having such a clear center of expertise within the staff would have made it the logical focal point for these questions and would prob-

making matrix before them on Friday morning suchas the one that was prepared for Sunday (see Appendix 111.5 to this section). Documents such as Appendix 111.5 should not be prepared from scratch
during an accident. As part of the emergency planning, matrices of this type should be prepared for awide range of events, including serious core melt
scenarios. These documents should present thebasic scenario, time sequence, and offsite consequences (for a reference meteorology condition) for
each of the events based on realistic analyses. The
analyses could include corrections that would apply
for different levels of decay heat. These tables
would then be in the possession of the principals
during an accident. Then expert advisors, whether
from the NRC or the plant operators, could give theiradvice on a common basis needing only to correct
for current meteorology and relying on their expert
judgment for the selection of an appropriate likelihood of suffering a specific scenario. Ideally, nuclear experts should be seeking to give local officials advice as understandable as that which isavailable for better understood hazards. We can allunderstand it when an expert from the National
Weather Service describes the size and intensity ofa hurricane and then tells the governor of a coastal
state that there is a 90% probability that the hurricane will cross the coast on a certain path at noon
tomorrow. The governor has what he needs tomake that difficult evacuation decision-the probability, the timetable, and the severity of the hazard.
I n a nuclear plant crisis, the nuclear experts should
give him equivalent advice.
How Dangerous was the Bubble?

Shortly after Chairman Hendrie endorsed Governor Thornburgh's advisory, he heard from Roger
Mattson the first intense concern about the bubbleof gas in the reactor coolant system. 202 The concern at first was that the bubble, estimated to be1000 cubic feet in volume, could expand and again
uncover the core. Mattson recommended a generalevacuation. We recognize that Mattson's concern
was genuine and that there was a possibility that
depressurization would uncover and melt the core.
The record does not show an orderly evaluation ofthis concern. What was the likelihood of deliberate
depressurization from all causes? What might thesequences of events be? At this time after cooldown, how long would it take for the core to melt?
We believe that an emergency planning matrix ofthe type described above, somewhat like Appendix
111. 5 would be invaluable for the evaluation needed.
I n retrospect, we believe that an orderly evaluation
98 1

ably have ensured a prompt, accurate appraisal of
the bubble's explosion potential, which we know
now was negligible. We suspect that the lack ofthis center of expertise in the NRC staff indicatesthat little attention was given to this area in the
NRC's safety review. Therefore, we recommendthat NRC establish a group within the staff with concentrated expertise in reactor chemistry matters.
The lack of a center of expertise for the hydrogen bubble problem illustrates a need to choose inadvance the consulting experts who will be called
upon in an emergency. At a minimum, the NRC staff
should establish an index of names of staff experts
who should be called on, organized by their technical specialty. These staff members should be able
to provide sound advice promptly or be a logicalchannel to obtain such advice from others.

Should the NRC Have Recommended Evacuation?

After reviewing the events at Three Mile Islandand especially the confusion about evacuation, it isnatural to ask whether the NRC should have recommended evacuation. This is second-guessing; wedo enjoy the greater clarity that always comes withhindsight. We want to address this question here,
not to find fault with past decisions, but to gain insight for making such decisions in the future. Our
analysis will not be based on additional facts gained
from months of investigation and evaluation. Instead, we will use only the information and insightthat was available at the time. We will consider theneed for evacuation in four different situations:

1. In the TMI-2 Control Room at 9:00 a.m. on
Wednesday, March 28
2. In the NRC Headquarters IRC at 9:15 a.m. on Friday, March 30
3. In the NRC H-Street Commission offices at 10:00
a.m. Friday, March 30
4. With the Commission in the NRC Headquarters at
3:00 p.m. Sunday, April 1

The Final Call for Evacuation

Late Saturday, at the behest of Jack Watson of
the White House staff, Commissioner Gilinsky asked
the NRC staff to prepare contingency evacuation
205
plans.
The result of the staff effort was the document reproduced in Appendix 111.5 to this section.
Here, for the first time in the TMI accident, the NRC
had put down its best evaluation of plant contingencies in a way that could be useful to the evacuation
decisionmaker. The document was sent to the sitewith Chairman Hendrie. The four remaining Commissioners met in Bethesda and reviewed the contingency analysis. The information that the Governor did not want to increase the state of the alert 20g
was a significant factor in the Commissioners' decision that precautionary evacuation was warranted.
To their credit, they did not make it a Commission
vote but presented their consensus to the Chairman
at the site. As Commissioner Kennedy, who called
Hendrie, told us:

Situation 1: in the TMI-2 Control Room at 9:00 a.m.
on Wednesday, March 28

This first situation is at a time and place where no
NRC person was present. The first NRC inspectors
reached the TMI-2 control ro: m about two hours
l ater, at 11:00 a.m. We chose this situation time,
9:00 a.m., because of the state of the plant and thei nformation that was then available. We postulate
the presence of a competent monitor, whether fromthe NRC or from the utility, who has been present
since early in the event and has been privy to thei nformation passed to the plant management.

Information Available
1.

We were not telling him as a collegial body, youhave just been given an instruction by a majority ofyour peers. We were telling him, the majority ofyour peers, from its own perception, sees it thisway, but recognizes that there may well be factors
which it doesn't know or comprehend in the same
way as you do on the ground there. That justseems to me simple, straightforward common
sense. 207

2.
3.
4.

5.

We believe that this was a sensible way for theCommissioners to interact with the Chairman insuch an emergency. We believe that this use of
methodological contingency analyses and orderly
consultation is good procedure for future emergencies facing the NRC.

6.
7.

982

Total loss of feedwater caused high pressure
reactor trip.
Power-operated relief valve (PORV) lifted.
Pressurizer level dropped and then started toi ncrease.
Low reactor coolant system (RCS) pressurecaused emergency core cooling system(ECCS) to come on; two makeup or high pressure injection (HPI) pumps were operating.
Operators bypassed HPI controls and reduced
HPI flow to prevent overfilling the system.
Pressurizer level went offscale high but system pressure was low.
Blockage of the auxiliary feedwater system
was discovered and corrected; effect on decay heat removal unknown.

8.
9.
10.

11.
12.
13.
14.
15.
16.
17.
18.

Pressure rise detected in reactor building.
Reactor coolant pumps not delivering rated
flow; operators began to shut some down; finally all were shut down.
Reactor coolant system hot- and cold-leg
temperatures began to diverge widely; hot-leg
temperature went offscale high at about 6:00
a.m.
Block valve to PORV was closed at about
6:20 a.m.; RCS pressure began to rise.
High radiation alarms were received from thesample station, the letdown line, and otherareas; a general emergency was declared.
Reactor coolant pumps could not be restarted,
appeared to be vapor bound.
Reactor coolant system appeared to be filledwith steam bubbles, superheat conditions
were seen.
Radiation reading in the containment building
was high and increasing.
Hot-leg temperatures went offscale high withsystem pressure usually at 1200-1500 psig.
Core exit thermocouples were measured
directly; some showed temperatures over2000°F.
Containment dome monitor reached 200R/h
reading.

Discussion-In this case, the NRC could give betteradvice to the local authorities if there were better
analyses done in advance, something similar to thedecision matrix developed by the NRC on Saturdaynight, March 31 (see Appendix 111.5). Core melt
scenarios and offsite consequences could be moreaccurately predicted then. Without such advancecalculation, only the few people most familiar withthese specialized analyses could give a relatively
precise timetable estimate for a core melt scenario
and judge whether the offsite doses would reachProtective Action Guide levels. Presuming the absence of such advance calculations for a basis, wehave had our postulated "well trained authority"offer the local authorities advice in terms of "a few
hours" and "a few miles," admittedly imprecise
terms. The outer radius of 10 miles is based on thel atest thinking published at the time of the TMI accident, 208 which arrived at a 10-mile radius forevacuation planning for core melt scenarios. We
are, of course, assuming that the postulated monitor
has read this important document on emergency
planning, which was published only 3 months before.
The difficult question in this situation is whether
to advise precautionary evacuation of the nearby
population or to advise only an alert for possible
evacuation. The recommendation to evacuate isconsistent with what we think would then be thecase, a prudent doubt that the core-cooling passages were still sufficient for cooldown. In addition,
the containment building was now filling with intensely radioactive gas and vapors, leaving the
nearby public protected by only one remaining barrier, the containment, a barrier with a known leakrate that needed only internal pressure to drive thel eakage. We presume the monitor would explain
this to the governor or other official and thus helpthat official make an intelligent decision-whichmight not be to evacuate immediately.

Actions That Appear Warranted
1. Advise or order plant that core appears to havebeen uncovered and thereby damaged. Maxi mum HPI flow should be provided to recover thecore, open PORV block valve for maximum reliefflow.
2. Advise State officials that the core has been badl y damaged and has released a substantial
amount of radioactivity. The plant is now in acondition not previously analyzed for cooling system performance. Presuming that full HPI flow isturned on, advise the State that if the coolingsystems do not function adequately, portions of
the core could begin to melt which could lead tosignificant offsite releases in a few hours. If thecooling systems are successful, evidence of thatsuccess should be available in a few hours.
Recommend to State officials that they begin aprecautionary evacuation of the first few miles
around the plant with an alert for a larger radius(10 miles) evacuation that may follow. Evacuees
from the inner zone of few miles' radius should
be moved to locations at least 20 miles distant.

Situation 2: In the NRC Headquarters at 9:15 a.m.
on Friday, March 30
Information Available

1. The core is badly damaged from the events ofWednesday.
2. The cladding apparently underwent a massive
metal-water reaction that released a large
amount of hydrogen and radioactive gas into thereactor coolant system and in the containmentbuilding.
3. Since Wednesday night, the circulation provided
by operating one reactor coolant pump was ap98 3

parently cooling the core; all temperature monitors indicate a cooling trend.
4. The pressurizer heaters and the reactor coolant
pump, needed for this cooling mode, are bothsupplied by offsite power only and are vulnerable
to its loss.
5. The gas bubbles in the system are large enoughto be a threat to the ability to cool the core.
6. The system is being degassed as rapidly as possible, stripping hydrogen and radioactive gas out
i nto the systems in the auxiliary -building. It is notknown yet whether degassing is removing the
bubble.
7. The waste gas storage tanks in the auxiliarybuilding have just been reported to be full. Thismeans there is no more holding capacity for theradioactive gas being stripped.
8. There has just been an unconfirmed report of an
uncontrolled 1200 mR/h gaseous release from "apoint in one of the cooling towers." The locationof the measurement is unknown.

Situation 3: In the NRC H-Street Commission
offices at 10:00 a.m. on Friday, March 30

Information Available

1. There were intermittent releases of radioactivegas from the plant. There is little knowledge ofthe period or pattern of the releases, but they appear to be hours apart. Offsite doses associatedwith these releases are about 10 mR/h.
2. The NRC Headquarters staff has recommended
evacuation to the State, but apparently with noeffect. Local authorities are challenging therecommendation, and the staff sounds uncertain
about reaffirming their recommendation.
3. The staff is getting more information from thesite, but only in a piecemeal fashion.
4. The Governor is asking for the Commission to affirm or deny the recommendation to evacuate.
Actions That Appear Warranted

1. Order the Headquarters staff to check all reports
with NRC personnel on site and with the Met Ed
plant management.
2. Notify the Governor that the previous evacuation
recommendation may have been unjustified.
3. Share all information gained with the Governor.

Actions That Appear Warranted

1. Contact NRC inspectors in the plant to verify thatthe waste gas tanks are full and to confirm thefacts related to the reported 1200 mR/ h gaseous
release.
2. Contact the Met Ed plant management directly toobtain their evaluation.
Discussion- The evacuation recommendation thatwas put out by the EMT under these circumstances
was clearly a precipitous action. The report that thewaste gas tanks were full, a significant development
when radioactive gas is being stripped into them,was sent from the site without remarks about consequent actions. At the least, this indicated that
whoever reported it didn't understand what was goi ng on. A direct check would have discovered thatthe tanks were not full.
Even without an EMT request to verify the 1200
mR/h release, some of the facts came in quicklyoffsite doses were on the order of 10 mR/h and therelease had stopped. There was clearly plenty of
ti me available to determine the facts and choose acourse of action.
We believe that there need not have been a
recommendation to evacuate at 9:15 a.m. Friday,
and we feel that there should have been such a decision on Wednesday at 9:00 a.m. What of the time
between, as NRC learned little by little how bad theaccident was? There is no simple answer to thatquestion because, as the NRC slowly learned of thesevere damage, it was also slowly obtaining evidence that the cooling flow, restored Wednesdaynight, was successfully cooling the core.

Discussion-It seems clear that if these procedures
had been followed the NRC and the Governor would
have had a clear basis for making their respective
decisions. From a technical point of view, there was
no apparent need to recommend evacuation. The
plant was still in a relatively stable cooldown and thegaseous releases were not large. There was still
great uncertainty about the final cooldown of theplant, but the situation was not significantly different
from the night before. Presumably, if there was noneed to evacuate then, there would be no need to
Friday morning. Nevertheless, the Governor might
have weighed all the facts at the beginning of theweekend and considered it prudent to remove manyof the more radiation sensitive people by issuing anadvisory. Later, if an evacuation were needed, themore sensitive population would for the most partbe gone, which would simplify the evacuation.
Situation 4: With the Commission in the NRC
Headquarters at 3:00 p.m. Sunday, April 1

Information Available

984

1. The plant is still cooling down very slowly.
2. There are mixed reports on whether the bubble isbeing removed from the reactor coolant system.
3. The oxygen content of the bubble may be increasing steadily. The gas composition may beat or very close to the threshold of ignition. Allavailable expertise is being applied to evaluate
the gas problems.
4. Spontaneous ignition on sharp metal edges ispossible.
5. The NRC staff in a prepared contingency plan
has recommended a precautionary evacuation toat least 2-miles radius if the gas mixture is in the
flammable range.
6. The contingency plan notes that an explosion
leading to a core meltdown (4-hour warning) oreven a breach of containment (24 hours to
failure) would warrant even more extensive evacuation.
7. The local authorities are in a state of readinessthat requires 4 hours callup notice before fully effective action can proceed. The Governor will
not change this state of readiness.

Friday and in situation no. 1 at 9:00 a.m. on Wednesday demonstrate a need for immediate surveillanceof important plant parameters, either by a competent monitor in the control room or through a datalink to such a monitor at a central location. Perhaps
both methods of surveillance should be used.
A second insight of value is the importance ofbelieving the best available information if it tells youthat something is wrong. Verify it wherever possible, but be willing to believe it. The temperature instruments said the core was uncovered; they
weren't believed and they should have been. You
won't always be right if you believe the best reports
available to you, witness the hydrogen bubble scare,but it is the proper course of action. The NRC's experience with the hydrogen bubble concern is adramatic example of a problem that regularly is encountered in safety regulation. How conservative or
pessimistic should you be? The NRC's worry about
the bubble caused great public concern. The NRC'sconcern was later shown to be essentially unfounded, bringing great embarrassment to the agency andsome of its principal staff. In retrospect we are all
relieved that the NRC was wrong and, at least in thisone respect, there was no danger to the public. But
i f these same officials are called to serve in anotheremergency, how pessimistic or conservative will
they be? How conservative do we want them tobe? Surely all of us would want them to be as reali stic as possible, but where doubt exists, be conservative.
A third important insight is the value of having
good contingency and emergency plans prepared.
If there has been good preparation, then the NRC
advisor and the State authorities can both have before them simple, understandable descriptions ofpossible events that entail the need for protective
action. The interpretation of actual plant events andthe intelligent evaluation of protective actions would
be thereby greatly helped. Without a prepared system, these interpretations and evaluations are very
vulnerable to gaps in the personal knowledge of theparticipants.

Actions That Appear Warranted

1. Continue working on the gas problem with all
available resources.
2. Advise the Governor that the 4-hour state ofreadiness for local emergency forces isincompatible with the best estimated deterioration
times available to the NRC.
3. Advise the Governor to increase the state ofreadiness or to begin a precautionary evacuationof the area near the plant.
Discussion- We now know that the concern Sun-

day about an ignitable bubble was unnecessary andwas based on overly conservative analysis of thesituation. Nevertheless, that was the best analysis
based on information available to the Commission at
the time. By Sunday the staff had prepared, atWhite House and Commission request, a procedure
for evaluating and recommending evacuation (Appendix 111.5). The Commission was right in following
this procedure.
Its recommendation, passed
through the Chairman at the site, was blocked when
Stello persuaded Hendrie that the gas bubble did
not contain oxygen. Although all parties now seemto agree that Stello was right on April 1, we believe
the four Commissioners acted correctly, basing their
judgment on the evidence available to them.

Findings

Based on the facts set forth in the narrative andthe evaluation of NRC's actions on evacuation issues, we make the following findings:

I nsights From Reconsidering Past Decisions

Reconsidering the Three Mile Island evacuation
decisions can give us some valuable insights. For
one, we see the obvious value of having the decisionmaker well informed. The Friday decisions
were flawed because of the lack of accurate information. The factors surrounding decisions made on

98 5

1. The first NRC inspectors to arrive on site confirmed that the emergency operations contacts
with the State were proceeding as planned.
2. Present emergency plans are inadequate because they do not provide a clear requirement toevaluate the need for protective actions based ondeterioration of plant conditions.

3. There was no clear NRC policy that provided guidance to the NRC concerning evacuation recommendations to State officials.
4. The NRC did not promptly and regularly consider
its obligation to give local authorities evacuation
advice based on the condition of the plant.
5. The NRC management did not make a clear andorderly decision about who in the NRC should be
the spokesman on evacuation and other protective measures, and to whom the spokesman
should make his recommendations.
6. The NRC staff failed to verity facts significant toprotective action decisionmaking before making
decisions to recommend such actions.
7. The NRC did not analyze and present hazard
data in an orderly way until Sunday, April 1.
8. The NRC consideration of evacuation based onfear that bubble expansion would uncover thecore was not done carefully or completely.
9. Using the services of too many different groups
without proper coordination, the NRC made apoor evaluation of the explosion potential of thehydrogen bubble.

spokesman concerning the emergency response
from the time of the team's arrival.
This authority should include the power to require
the licensee to take such action as the onsite teamleader deems appropriate to ensure adequate protection of the public's health and safety. Also included should be the authority to make a final
recommendation to State and local officials onbehalf of the NRC about the appropriateness ofvarious protective actions, including evacuation.
The onsite team leader's authority should bemade known through preplanned notification procedures to all NRC officials, officers and employeesof the licensee, and appropriate Federal, State, andl ocal officials.
The functions of the onsite team should include
the following: (1) observing, evaluating, and reporti ng on operational and radiological status and activities; (2) giving advice or orders to the licensee regarding accident recovery; and (3) advising Stateand local authorities on public protection actions. A
program plan should be prepared in each region ensuring that, to perform these functions, the onsiteteam will consist of a sufficient number of individuals
with substantive training, experience, and a detailed
understanding of the particular plant involved.
Regional project inspectors or, where applicable,
resident inspectors should be part of the onsite
team. These managers and inspectors must all
have extensive exposure to the plant and goodknowledge of its design, layout, operating procedures, and other essential information.
Procedures should be prepared that explain indetail the role of the onsite team. Team members
should be adequately instructed as to who is teamleader, what they should do upon arriving at the site,what to look for and report, to whom to report, andfrom whom they will receive further instructions.
The procedures should describe the emergency
response structure that will be organized by thelicensee during an emergency. These proceduresshould include the names and emergency telephone
numbers of individuals given direct supervisory authority over the licensee's overall emergency
response, and over operational and onsite radiological matters.
The procedures should describe State and local
officials and offices that may play a role during the
emergency, including the names and emergency
telephone numbers of those officials who may haveto be contacted and what their role will be in an emergency.
Upon arriving at the site, the onsite team should
set up an operations center at a predesignated location, to which all available information concerningc. Summary of Recommendations for NRC
Emergency Response
Based on the evaluation and findings presented
i n the preceding sections, we make the following
recommendations regarding
NRC emergency
response:
NRC's Emergency Response Organization at theSite

I n an emergency of predetermined severity, the
NRC should send an emergency response team tothe site. The team should be drawn principally frompersonnel in the appropriate regional office, not from
Headquarters. What is presently termed a "Level 1"
emergency should always require the activation ofthis team. Through planning, the NRC should set
standards determining the extent to which a "Level2" emergency will require the activation of theemergency response team.
Whenever this team is activated and sent to thesite, its leader should be the regional director or theregional official who, in the absence of the director,
normally would become the acting regional directorof the organization.
The onsite team leader should have the delegated authority to manage and direct the NRC's entire
emergency response, and to be the agency's
98 6

plant and offsite conditions will be transmitted. The
licensee should set up a similar operations center at
the same location. NUREG-0578 proposes thatevery licensee set up an "onsite operational support
center." This center would be the logical location
for the regional onsite team's operations center inan emergency.
Upon arriving at the site, the onsite team shouldi mmediately establish and maintain telephone contact with those individuals whom the licensee has
designated to have direct supervisory authority.
Recognizing the onsite team leader's obligations
as agency spokesman, the onsite team should beorganized so that the team leader's deputies andprincipal managers in the everyday organizational
structure are designated and prepared to assume
primary responsibility for supervising the work of all
NRC personnel at the site. These deputies andprincipal managers should be able to establish immediate verbal contact with the onsite leader at all
ti mes.

tain telephone contact until the arrival of the region's
onsite team, which will then assume control.
Once the onsite team leader takes command, thefunction of the personnel at the Headquarters Incident Response Center should be to provide support and advice to the onsite team when and as requested by the onsite team leader. Headquarters
should no longer manage or direct the NRC's
response.
The Headquarters Incident Response Plan should
describe the support and advisory functions that
may have to be performed in any given emergency,
and should specify which component office at
Headquarters will be responsible for providing eachsuch function. The plan should also describe themanagement structure each office will use indischarging an assigned function, as well as the
structure that will be used to coordinate the work of
all component offices. One individual from eachcomponent office should be designated ultimate
responsibility for, and authority over, the work of theoffice. Similarly, one designated individual shouldcommand and be ultimately responsible for thecoordinated work of all of the offices involved. This
person should preferably be someone in the NRC's
everyday organization, such as the EDO or a Commissioner, who has authority over the component
offices.
Except for the command function at the incident
response center just discussed, the Commission
should not interject itself into the management's
response to an emergency. The predesignatedemergency response organization should be reliedon. We expect that individual Commissioners willkeep closely informed and act as spokesmen within
the government.

NRC Headquarters
When the NRC is first notified of an emergency
requiring activation of an onsite team, NRC Headquarters officials should manage and direct theagency's emergency response until the onsite teamarrives at the site. Once the onsite team leader notifies Headquarters of his arrival, however, full authority must pass to the onsite team leader and his
team.
A duty officer should be available at the Headquarters Incident Response Center on a round-theclock shift basis. When notified of an emergency
requiring activation of an onsite team, the duty offi cer should supervise activation of the Headquarters' center. He also should notify the director of IE,
or an individual previously designated by the IE
director, to come to the incident response center assoon as possible. The duty officer, and then the IE
director or his designee, should be responsible formanaging and directing the NRC's emergency
response until the onsite team leader assumes command.
Immediately upon notification of an emergency
requiring activation of an onsite team, the Headquarters duty officer should establish telephone
contact with individuals to whom the licensee hasdelegated direct supervisory authority. (At the beginning of an emergency, the licensee's designatedindividuals, like the Headquarters duty officer, may
have only interim authority pending the arrival ofother licensee officials.) Headquarters should main-

Communications and Equipment
Automatic data retrieval systems should be
developed to telemeter important plant data to theonsite response team's operations center, as wellas to the affected region office and the Headquarters Incident Response Center.
Permanently open communication pathways
should be maintained between each site and the region and Headquarters response centers. These
communication lines should be backed up by alternative means of communication resistant to loss
from possible environmental conditions (tornado,
earthquake, and hurricane). The number of suchpermanent pathways should be determined on thebasis of the data transmittal needs. As a minimum,
separate pathways for operating and radiological in98 7

formation should be provided. Following an accident, each end of the permanent communication
li ne should be continuously manned as soon as
possible by NRC personnel who have been trained
to ensure the adequacy and completeness of the information transmitted.
In an emergency, the oral communication of information among the onsite team, the regional office,and Headquarters, should be the responsibilities ofi ndividuals specifically assigned only to this task.
They should have technical familiarity with the typeof information being requested and transmitted, andshould be trained to ensure the adequacy and completeness of the information transmitted.
The oral communication of information should betransmitted by the most direct means possible tothe party having the principal need for the information. Thus, to the extent possible, emergency plans
should establish communications priorities concerni ng the different categories of information. For example, the operations center of the region's onsiteteam should have first priority regarding all operations data. With respect to offsite radiological data,
communications priorities should be establishedamong the State, the region's onsite teams, or others who may have need in an emergency.
Each region should have available what has previously been determined to be the emergency
equipment required to perform all necessary independent measurements, and to enable the NRC
emergency response team to fulfill its mission. Allsuch emergency equipment should be carried to thesite by the onsite inspection team, or otherwise
made available to them immediately upon arrival.
The equipment should include portable communications equipment, portable air sampling devices, andprotective equipment required for working in contaminated areas. Capabilities for quickly analyzing
fission-product contaminated air and reactor
coolant samples should be provided.

and environmental releases following a nuclear accident.
The NRC's present policy referred to in paragraph 024 of Manual Chapter 0502, "NRC Incident
Response Program," should be clarified. The NRC
should prepare and publish a policy statement concerning whether and under what conditions the NRC
will intervene to direct recovery actions following an
accident. The statement should clarify the responsibilities of licensee management unless and until
these are preempted by the NRC.
The NRC should consider in advance the assistance that will be needed by the State, the licensee,
the NRC, and other Federal agencies in any nuclear
accident. A determination of what will be needed
and what party can and will satisfy the need should
also be made. Agreements should be establishedbetween the NRC, the DOE, and other agencies as
to what each will do in an emergency, and how andby whom the activities will be coordinated to ensurethat all assistance and information needed by eachof the parties is provided.
Protective Action Evaluation

The region's onsite team and the Headquarters'
support team should each include a distinct group of
officials whose assigned function is to evaluate contingencies. The group must be prepared to evaluate
the chance of various contingencies actually occurring; the estimated type, magnitude, and timing ofradiological releases in the event a contingency occurs; the likely exposure pathways resulting fromsuch releases; and other matters weighing in favorof evacuation or other protective action.
The NRC support team at Headquarters should
be organized in advance to identify centers of expertise for different technical areas. Based on thebad experience in one particular area during the TMI
response, the NRC should establish within the staff
an organization with concentrated expertise in reactor chemistry matters.
The contingency group should appraise the needfor public protective measures as soon as possible
after responding to an emergency. This appraisal
should explicitly consider both the known state of
the plant and possible deterioration in the plant's
condition. The appraisal should be repeated whenever there is a significant change in the situation.
The results of the appraisals should be communicated promptly to predesignated State and local officials.
The NRC should have a clearly identified single
spokesman for making recommendations on protective actions. There should be advance knowledge

Notification Procedures

The region and Headquarters' incident response
centers all should have duty officers available on around-the-clock basis to immediately receive thelicensee's notification of an accident.
The Role of the Agency

The NRC should prepare and publish a policy
statement concerning its role in responses to nuclear accidents. This statement should describe theextent to which the NRC will independently collectand evaluate data relating to reactor safety systems
98 8

on the part of State and local officials as to who this
NRC spokesman is, with whom he will consult, andto whom he will make his recommendations. The
spokesman for NRC should be the onsite teamleader.
The NRC should prepare multiple plant accident
and offsite hazard descriptions for each plant using
realistic analyses and reference meteorology conditions. These descriptions should cover a wide
range of serious accidents, including core melt sequences. They should be made a part of the emergency plan documentation so that all parties may
refer to them readily during an accident.
I nforming the State, Congress, Other Federal
Agencies, the Media, and Others

The NRC should develop a policy about dealing
with briefing requests from State and local officials,
Congress, other Federal officials, the media, andothers during emergencies. The policy should require that a special onsite team having no other rolei n the response activities, be made available togather the latest facts and to brief the requesting
agencies and individuals at frequent intervals. At
least one such spokesman should be a senior NRC
official. Members of this team who are responsible
for transmitting information to people lacking technical expertise must have previously demonstrated anability to explain technical information accurately in
l ayman's terms.
The NRC should advise all other response teammembers-at Headquarters, the regional office, andat the site-to defer to the special team withrespect to media briefings or discussions. A single
location at or near the site for all media briefings
should be considered. The NRC should provide guidance on what type of information is to be made98 9

available to the public to ensure they are kept informed of factual information, but are not panickedby rumors and unfounded or highly speculative information.
The informaton policy should be issued, alongwith an implementing procedure, as part of theemergency response plan. The NRC should informthe States, the Congress, the media, and the publicof this policy, and request that they work only withthis special information group. The NRC should be
prepared to request that all State and Federal officials, including those from Congress, refrain fromvisiting the site of an accident or requesting heari ngs or formal briefings if such visits will interferewith the NRC's ability to fulfill its primary responsibility for the health and safety of the public.
The NRC should intensify its efforts to keep upto-date information on nuclear accidents available
on a prerecorded tape accessible to the public bydirect dial phone.
I ndividuals who write preliminary notification documents (PN's) should be properly trained and instructed to prepare PN's for nontechnical readers.
Highly technical terms should be avoided to the extent possible, and the significance of reported information should be explained.
The NRC should prepare and be able to provide
to government officials and others appropriate documents to assist them in understanding technicalexplanations provided by the NRC staff during or
after a nuclear accident. These documents should
i nclude primers on reactor operation, biological effects of radiation, and radiation protection terminology and concepts. Schematic drawings of plantsystems and plot drawings that show how reactor
systems interact and where the site is located in rel ation to nearby communities and environment monitoring stations should be available.

REFERENCES AND NOTES
Hq. IRC Day 1 Transcript 01-115-CH4/22-EG-3.
NRC Manual Chapter 0502, "NRC Incident Response
Program," identifies three levels of incidents based on
severity as follows:
Level I-There is an actual or imminent serious threator hazard presented; activation of the NRC Incident
Response Program required.
Level II-There is a potential serious threat or hazard,
activation of the NRC Incident Response Program recommended.
Level III-There is no immediate potential threat or
hazard, or there are relatively insignificant effects; Level III
incident response is under the purview of the appropriate
li ne office.
40
Neely dep. at 5; Gallina dep. at 8.
41
Hq. IRC Day 1 Transcript 01-258-CH7/25-EH-4.
42
Ahearne dep. at 15.
43
Hq. IRC Day 1 Transcript 01-066-CH3/21-PD-2.
"Thompsondep. at 159,160.
45
Neely dep. at 6; Gallina dep. at 12; Higgins dep. at 15.

42 U.S.C. 5841, Sec. 201(a)(1).
2
42 U.S.C. 5841, Sec. 201(a)(2).
3
Kennedy dep. at 215.
4
Hendrie actually held these positions in the NRC'spredecessor organization, the Atomic Energy Commission.
5"Headquarters" as used in this section refers generally to the NRC offices in Washington, D.C. and the
Maryland suburbs.
6
42 U.S.C. 5843, Sec. 203(b)(1) and (2).
7
"Early TMI Reports Sounded Like 'China Syndrome,'"p. 25, The Washington Star, June 11, 1979.
8
Energy Reorganization Act of 1974, Pub. L. No. 93438, Sec. 310, 88 Stat. 1253 (amending 5 U.S.C. Secs.
5315-5316).
9
Sniezek dep. at 9, 21.
10
Gossick dep. at 10-11 (Pres. Com.).
11NRC, "NRC Headquarters Incident Response Plan" at
4.1.2.
12
Id. at Appendix II.C.
13
Gilinsky dep. at 19.
14
Hendrie dep. at 21.
15
NRC, "NRC Incident Response Plan," Appendix I.B.14 andII.D.1.
16
Gossick
dep. (Sept. 28,1979) at 15-16.
17
Id. at 17.
18
NRC, "NRC Headquarters Incident Response Plan,"
Appendix
II.E.2.
19!d. at Appendix II.D.2.
20
Moseley dep. (Sept. 25, 1979) at 11; Stello dep. at
87.
21
Sniezek dep. at 6; H. Thornburg dep. at 9; J. Davisdep. (Sept. 11, 1979) at 18-22.
22
Moseley dep. (Sept. 25,1979) at 11.
23
NRC, "NRC Headquarters Incident Response Plan,"
at 4.1.1, 4.2.1, 4.2.3.
24
14. at 4.2.1.
25
Id. at Appendix II.E.3.
26!dat 4.2.2.2.1.
27
NRC, "Office of Inspection and Enforcement, Region
I Incident Response Plan" at 1.2(b)-(d).
28ld. at 1.0(c).
29
Id. at 8.1.15.
30!d. at 1.0(a).
3'ld. at 1.2.b.
32
Id. at 1.2.c.

38

1

33

39

48

Higgins dep. at 26.

14 at 28.
48
Id. at 38, 39.
47

49

Hq. IRC Day 1 Tape 01-033. The conversation istranscribed with errors and omissions at Transcript 01033-CH2/20MEM-6.
50
Hq. IRC Day 1 Transcript 01-226-CH6/24-LFR-6.
51
Hq. IRC Day 1 Transcript 01-226-CH6/24-LFR-8.
52
Hq. IRC Day 1 Transcript 01-226-CH6/24-LFR-9.
53
Hq. IRC Day 1 Transcript 01-226-CH6/24-LFR-10.
54
Hq. IRC Day 1 Transcript 01-226-CH6/24-LFR-11
and55-12.
Hq IRC Day 1 Transcript 01-226-CH6/24-LFR-14
and56-15.
Hq. IRC Day 1 Transcript 01-226-CH6/24-LFR 15.
57
Stello dep. at 24.
58
Higgins dep. at 51, 52.
/d. at 17.
Hq. IRC Day 1 Transcript 01-222-CH6/24-LFR-10
and -11; Transcript 01-223-CH6/24-LFR-1, -2, and -3.
81
Vollmer dep. at 12.
62
Hq. IRC Day 1 Transcript 01-126-CH4/22-HF-1.
59
60

63

Grier dep. (Oct. 12,1979) at 8.
Higgins dep. at 26.
65
dat 28, 29, 30.
66
Hq. IRC Day 1 Transcript 01-01287-CH7/25-EH-1
and -2.
67
Stello dep. at 71.
68
NRC Commission Meeting Transcripts (March 29,1979) at 7.
69
Id. at 10.
70Ad.
at 20.
71Id. at 21.
72Ad.
at 23.
73
Eisenhut dep. at 76.
74
NRC Commission Meeting Transcripts (March 29,1979) at 25.
64/d. at RIP-6.

34NRC, "NRC Headquarters Incident Response Plan,"

Appendix II.E.1.c.
35

NRC, "Office of Inspection and Enforcement, Region
I Incident Response Plan" at 8.1.15.
36NRC, "NRC Headquarters Incident Response Plan"
at 4.1.2.
37

NRC, "Investigation into the March 28, 1979 Three
Mile Island Accident by Office of Inspection and Enforcement," Investigative Report no. 50-320/79-10 (NUREG0600), August 1979 at 1-3-39.
99 0

75

115

Id. at 13.

118

76ld. at 32.

Gallina dep. at 57.
Hendrie dep. at 86.
'*This statement is quoted in "Meltdown Looms as a
Threat," p. 6, New York Daily News, March 31,1979.
120
NRC Commission Meeting Transcripts (March 30,1979), tape 5, side 1 at 6.
121
Bradford dep. at 105, 106.
122
Hendrie dep. at 94.
123
Id. at 95.
124
Gerusky dep. at 64 (Pres. Com.).
125
Transcript of Governor's press conference, March
30, 1979.
126
Hq. IRC Day 3 Transcript 03-215-CH6/24-ab-1 and-2.
127
NRC Commission Meeting Transcripts (March 30,1979), tape 6, side 1 at 5.
128
Mattson dep. (Oct. 17,1979), at 83-84.
129
Case dep. at 117.
13
°NRC Commission Meeting Transcripts (March 30,1979), tape 12, side 2 at 10.
131
Hendrie dep. at 156.
132
Memorandum from J. A. Califano, Jr., HEW, to J.
Watson, White House Aide, "Three Mile Island Nuclear
Power Plant Accident," dated March 31, 1979.
133Hq. IRC Day 4 Transcript 04-099-CH4/22-sw-6.

77

117

Id. at 33, 34.
78
Mattson dep. (Sept. 24,1979) at 31, 32, 33.
79118

Case dep. at 72, 74.

Stello dep. at 69.
Hearing before the Subcommittee on Energy and theEnvironment of the House Committee on Interior andInsular Affairs, 96th Cong., 1st Sess. at 31 of transcript(March 29,1979).
80
81

Id. at 49-50.
Hq. IRC Day 2 Transcript 02-228-CH6-Kd-2, -3,
and -4.
82
83

Hq. IRC Day 2 Transcript 02-234-CH6-DC-5.
Hq. IRC Day 2 Tape 02-073. The conversation istranscribed with errors and omissions at Transcript 02073-CH3/ 21-SAC-2.
84
85

NRC, "Investigation into the March 28, 1979 Three
Mile Island Accident by Office of Inspection and Enforcement," Investigative Report no. 50-320/79-10 (NUREG0600), August 1979, Appendix II-A at II-A-58.
87
Vollmer dep. at 22.
88
Id. at 31, 32.
89
Denton dep. (Oct. 4,1979) at 92, 93.
90
President's Commission, "Report of the Office ofChief Counsel on Emergency Response," October 30,
1979 at 30-31.
91
Hq. IRC Day 2 Transcript 02-212-CH6-CLB-5 and-6. 92Barrett dep. at 42, 43 (Pres. Com.).
93
NRC Region I Incident Message Form, Control no.
C-56.
94
Higgins dep. at 80-89.
95
Barrett dep. at 45, 46 (Pres. Com.).
96
Hq. IRC Day 3 Transcript 03-259-CH7/25-PD-2.
97
Denton dep. (Oct. 4, 1979) at 73, 74, 80, 81.
88

98

Denton dep. (Oct. 23, 1979) at 11.
Denton dep., Exhibit 5090 at 8.
1w
Denton dep. (Oct. 23, 1979) at 12.
137
Id. at 15.
38' /d. at 13.
139
NRC Commission Meeting Transcripts (March 30,1979), beginning tape 10, side 1 at 13.
14
ODenton dep. (Oct. 23,1979) at 29.
141
Denton dep., Exhibit 5090 at 8.
142
Denton dep. (Oct. 23,1979) at 19.
143
J. Collins dep. at 29, 30.
14.1
Id. at 124.
145
Denton dep. (Oct. 23,1979) at 15.
148Id. at 15, 165.
147
Grier dep. (Oct. 12,1979) at 12, 13.
148Id. at 13.
149
Id. at 13-15.
150
Higgins dep. at 78.
151
Denton dep. (Oct. 23, 1979) at 12.
152
Hq. IRC Day 4 Tape 04-198. The conversation istranscribed with errors and omissions as Transcript 04198-CH6/ 24-LFR-6.
163
NRC Commission Meeting Transcripts (March 31,1979), continuation of meeting at 12:00 noon at 4.
154
0. at 15.
155
Higgins dep. at 93 and 94.
156
Gilinsky dep. at 81.
157 Id. at 82.
158
Hendrie dep. at 150.
159
NRC Commission Meeting Transcripts (March 31,1979) tape 3-A at 3.
1 34
135

Id. at 86.

Case dep. at 100-101 and Exhibit 5092.
0ase dep., Exhibit 5182 at 70.
1 1° Case dep. at 107-109.
102
Denton dep. (Oct. 4, 1979) at 92.
1 3
0
Id. at 105.
104
Gossick dep. (Sept. 28,1979) at 110.
105
J. Davis dep. at 165, 166.
106
Denton dep. (Oct. 4,1979) at 88.
100

107

Id. at 111.
Hq. IRC Day 3 Transcript 03-019-CH2/20-sw-10
and -11.
109
H. Collins dep. at 33.
108

11°NRC Commission Meeting Transcripts (March 30,1979), tape 1, side 1 at 5 and 6.
111

112

.

Id. at 4.
Id. at 7.

at 16.

Bradford dep. at 122-25.

"NRC Commission Meeting Transcripts (March 30,1979), tape 1, side 1 at 19.
114

NRC Commission Meeting Transcripts (March 30,1979), tape 2, side 1 at 3.
99 1

187

Hq. I RC Day 4 Transcript 04-092-CH3/21-sw-4.
Case dep. at 147-160.

Hq. I RC Day 1 Transcript 01-222-CH6/24-LFR-3-5.
Hq. I RC Day 1 Transcript 01-225-CH6/24-LFR-5-9.
189
President's Commission, "Report of the Office ofChief Counsel on Emergency Response," October 30,
1979 at 54, 134.
19
ONRC Commission Meeting Transcripts (March 30,1979) at 31-32.
191
Grier dep. (Sept. 28, 1979) at 25.
192
NRC Commission Meeting Transcripts (March 30,1979) at 31-32.
193
Hq. I RC Day 2 Transcript 02-212-CH6/CLB-1-7.

160

188

182

Case dep., Exhibit 5182 (Cassette 2) at 33-37,
44-45.
18314.
at 44 (Cassette 2).
164
Id.
at 45 (Cassette 2).
165
Case dep. at 172.
166
Mattson dep. (Sept. 24,1979) at 254-256.

Levine dep. at 62, 63.
Denton dep. (Oct. 23, 1979) at 85.
1 9
s Mattson dep. (Oct. 17,1979) at 66, 67.
170
Denton dep. (Oct. 23, 1979) at 33-41.
171
Id.
at 42-48.
172
Lazarus dep. at 4-5.
173
Neely dep. at
5; Gallina dep. at
8-9; Higgins dep. at
9-10.
174
George Smith dep. at 6-7.
175
Grier dep. (Sept. 28,1979) at 5-6.
176
Hq. IRC Day 1 Transcript 01-850-CH19/2030-SW5-6.
177
Higgins dep. at 9.
178
PIumlee and Nimitz Interview on May 30, 1979 (IE)
at 23.
179
VoIlmer dep. at 12-16.
180
Hq. IRC Day 1 Transcript 01-223-CH6/24-LFR-1-2.
181
Case dep. at 66-71; John Davis dep. (Sept. 11, 1979)
at 149.
182
Moseley dep. (Sept. 25,1979) at 21-23.
183Case dep. at
10-18.
184
Higgins dep. at 51-55.
185
Stello dep. at 34-35.
186
Hq. IRC Day 5 Transcript 05-215-CH6/24-1-4;
Grier dep. (Oct. 12,1979) at 9.
187
168

194

Higgins dep. at

196

NRC Region I Incident Message Form, Control no.

195

C-56.
197

1f8

67.

R. Thornburgh dep. at

39-40 (Pres. Com.).

Hq. I RC Day 3 Transcript 03-259-CH7/25-Pd-1-2.
Barrett dep. at

50-74 (Pres. Com.).

199

Hq. IRC Day 3 Transcript 03-019-CH2/20-Sw-8-11.

2o1

Gossick dep. (Sept. 28,1979) at 115.

200

Denton dep. (Oct. 4, 1979) at 105.

202

NRC Commission Meeting Transcripts (March 30,1979) at 57 et. seq.
203
204

205
206

Appendix 111.4 of this report.

Mattson dep. (Oct. 17, 1979) at 36.
Gilinsky dep. at

81.

Kennedy dep. at

40.

NRC Commission Meeting Transcripts (April 1,
1979) at 120.
207
208

"Planning Basis for the Development of State andLocal Government Radiological Emergency Response
Plans in Support of Light Water Nuclear Power Plants,"
NUREG-0396, at 24, December 1978.

99 2

C RESPONSE OF STATEAND FEDERAL
AGENCIES (EXCEPTTHE NRC)
During the accident at Three Mile Island, the NRC
and the utility were primarily charged with tasksarising from the first two of these objectives.
Achievement of the last of these, and some aspectsof the second, lay within the domain of other
Federal and State agencies.
The TMI accident initiated an institutional andpublic response that was unprecedented in the history of nuclear power in the United States. Twodozen Federal agencies, a dozen agencies of theState and 27 counties of the Commonwealth ofPennsylvania, innumerable local jurisdictions andpublic and private organizations, four borderingStates, and several national, quasi-Federal organizations participated substantially in the response tothis accident.
These institutions provided many kinds of support services: to Metropolitan Edison in evaluating
the status of the plant and in bringing the plant to asafe shutdown condition; and to the Commonwealthi n evaluating the extent of public hazards, in prepari ng for possible evacuation, and in considering or
preparing for the implementation of other protective
actions. A State is the principal governmental entity

1. INTRODUCTION
Whatever can be done to prevent or mitigate theconsequences of nuclear powerplant accidents or
to protect public health and safety or property afteran accident, one cannot preclude the possibility that
accidents having serious offsite consequences will
occur. Therefore, to minimize the effects of such
accidents on public health and safety and on property, effective emergency response should seekto:• Prevent minor reactor accidents from becoming

accidents with significant onsite or offsite radiological consequences.
• Reduce the duration and magnitude of radiological releases from any accident through appropriate plant-related actions.
• Reduce the offsite effects of any radiologicalreleases by assessing radiological hazards andi mplementing appropriate protective measures
which must include disseminating unambiguousand easily understood information and instructions pertaining to the releases.
99 3

responsible for protection of its citizens. Although
the NRC clearly has Federal jurisdiction over events
li ke those at TMI, it has no authority over offsite activities and can only make recommendations to a
State regarding such activities. Other Federal agencies have no jurisdiction over plant activities and little or no jurisdiction over offsite activities, thus theirrole basically is to provide assistance to a State andto the NRC.
Because of the scope and complexity of the
response, we chose to identify and evaluate the effectiveness of the integrated response, as opposedto performing a more laborious, time-consuming,and almost impossible detailed assessment of eachagency's response. The rationale is that an accident such as the one at TMI will result in a similar
multiagency response, and there is much more interest in the overall success of the response than in
an agency-by-agency report card. Under this approach, the possible weakness of one agency's
response could be offset by the strength of anotheragency's response in performing the same or asimilar function. Such a weakness would not be
critical and would not be underscored in our
analysis. If it were critical, this fact would become
apparent during the analysis of the total response.
Our analysis also would not likely highlight areas
where response was excessive, or where unnecessary duplication of effort occurred; it attempts to assess only the adequacy of response, i.e., successversus failure. Furthermore, as in the case of mostinquiries, we have given more attention to failure
than to success.
We have divided the response into several different functions, and each function is discussed in a
separate section of this report. We have tolerated
some repetition of chronology in order that a reader
primarily interested in only one of the response
functions will find the story easier to understand.
The first section provides a recitation of thehighlights of the "Emergency Response Chronology." This is provided to give the reader a general
temporal impression of the type and magnitude of
response, keyed to various changes or perceived
changes in plant status and to other events, and ispresented in narrative form. Appendix 111.8 furnishes
the reader with a more detailed portrayal of dayby-day events.
The next section provides an overview of"Federal and State Authorities and Responsibilities,"
together with an analysis of the status of the overall
coordination and command structures (or lackthereof) in place at the time of the TMI accident.
This section also necessarily highlights the important roles in coordination played by the WhiteHouse and the Governor's office during the firstweek of the accident.
Detailed accounts of "Sheltering and Evacuation
Advisories," "Evacuation Planning Before and During
the Accident," including an assessment of evacuation capabilities, and "Other Protective Actions"considered or implemented to provide protection
against radiological exposures, such as the possible
use of potassium iodide, are then discussed. Thesestories are told in chronological form with sufficientcommentary to give the reader some feeling for thepressures that existed during the accident and forthe amount and quality of information that was (orwas not) available, information upon which decisions
had to be made.
The section on "Radiological Monitoring Efforts"
provides a discussion of the institutional response
to provide adequate radiological monitoring of theenvironment and to assess the anticipated radiation
doses to people. A more detailed technical accounting of the physical measurements made andthe assessments performed is provided in the previous Section 11.13, entitled "Radiological Releases."
A section on "Institutional Communications During
the Accident" is also included. Although integral tothe effectiveness of all other emergency response
functions, we believe that this subject is of suchfundamental importance to effective response that it
deserves to be discussed in a separate section,even at the expense of some repetition. The discussion treats the adequacy of communications
networks and the effectiveness of human communications, once established.
A brief account of the "Technical Support for the
Plant" provided by government agencies is discussed. Although much of this support was provided by the NRC, Metropolitan Edison, Babcock &Wilcox, and a host of other industry organizations
and consultants, many services and much equipment were provided to the plant by other Federal
agencies and their contractors.
The last section provides a "Summary of theFindings and Recommendations" contained in thisportion of the report. It represents a synthesis of
the findings and conclusions provided in each of theanalytical sections. The interested reader is encouraged to examine the additional details available
i n these sections to gain a fuller understanding of
the intent of and need for the summarized recommendations.
There are two appendices other than the one
providing detailed chronology (111.8). Appendix 111.7
provides an agency-by-agency summary of authorities and responsibilities for emergency response,tells in detail how each agency first became involved
99 4

a Site Emergency, 2 began notifying offsite agencies.
Within 15 minutes the plant had called the duty officer of the Pennsylvania Emergency Management
Agency (PEMA); the Radiological Assistance Program (RAP) office of the Department of Energy(DOE) at the Brookhaven National Laboratory on
Long Island, New York; the Emergency Management
Agency of Dauphin County, where the TMI plant islocated; the Pennsylvania State Police; and theanswering service of the NRC Region I office in Kingof Prussia, Pennsylvania. The PEMA duty officer, inturn, contacted the Pennsylvania Bureau of Radiation Protection (BRP) and the emergency management offices of the three counties within 5 miles ofthe plant-Dauphin, York, and Lancaster.
At 7:24 a.m. the reactor building dome monitor
alarm sounded, indicating a radiation reading ofgreater than 8 R/h at the top of the reactor building.
(Because the dome monitor is shielded, it was expected to read about a factor of 100 less than theactual radiation level. Thus, the reading of 8 R/h
i mplied an actual radiation level of 800 R/h.) Since
this high reading indicated that there could be substantial offsite consequences in the event of a containment leak, Gary Miller, the Station Manager, who
had arrived on site about 15 minutes earlier in
response to a directive from Jack Herbein, Met Ed
Vice President for Generation, declared a General
Emergency. 2 His declaration triggered a second
round of notifications, whereby plant personnel
again called the officials they had first alerted lessthan half an hour earlier. Meanwhile, Thomas Gerusky of the BRP had called the Unit 2 control room at
7:25 a.m. to confirm the earlier notification BRP had
received from PEMA; he was advised that the situation had escalated to a General Emergency. The
telephone line between the control room and BRP
that had carried Gerusky's call was held open overthe next 2 weeks. It served as the principal communications link between the utility and the State forthe duration of the accident.
I n addition to the above notifications, PEMA
called Pennsylvania's Governor Thornburgh, Lt.
Governor Scranton, and the State agency membersof the Pennsylvania Emergency Management Council. PEMA also alerted the Region 2 office of the
Defense Civil Preparedness Agency in Olney, Maryl and. The Brookhaven Area Office of the Department of Energy alerted the Emergency Operations
Center at DOE Headquarters in Germantown, Maryl and, which, in turn, notified various DOE subgroups,
the National Military Command Center in the Pentagon, and the Joint Nuclear Accident Coordinating
Center3 i n Albuquerque, New Mexico. At 10:00 a.m.,the DOE Emergency Operations Center placed its

i n the TMI accident response, and describes what
each did. Appendix 111.9 provides a brief summary ofFederal legislation and executive actions related toemergency response that, as of December 6, 1979,
has occurred since March 28,1979.
2. EMERGENCY RESPONSE CHRONOLOGY
a. Introduction

During the early morning hours of Wednesday,
March 28, 1979, the Three Mile Island Unit 2 (TMI-2)
facility of the Metropolitan Edison Company (MetEd) was operating normally, generating about 870
megawatts of electricity. At about 4:00 a.m., theplant suddenly experienced a total loss of the feedwater supply to the steam generators, resulting inan almost simultaneous shutdown or "trip" of themain steam turbine. With no feedwater supply tothe steam generators, heat was no longer being removed from the reactor, and the reactor coolant
system temperature and pressure began to increase. Approximately 3 seconds later, the pilotoperated relief valve opened at its setpoint pressureof 2255 pounds per square inch, absolute (psia), torelieve the excess pressure in the reactor coolant
system. About 8 seconds after the turbine trip,
upon receiving a high pressure signal from the reactor coolant system, the reactor protection system
dropped the control rods into the core to shut down
the reactor. This was the beginnirg of the TMI-2
accident.
During the ensuing 2% hours, the plant operators
attempted unsuccessfully to bring the plant undercontrol' At 6:55 a.m., on the basis of high radiation
alarms received from process and area radiation
monitors, the TMI-2 Shift Supervisor declared a Site
Emergency.
The Shift Supervisor's declaration of a Site
Emergency triggered a series of responsive actions
by various Federal, State, local, and other agencies.
These actions were aimed, broadly, at controlling
the technological consequences of the accident at
TMI and protecting the local populace. This sectionof the report provides a brief chronological summaryof the actions comprising the official emergency
response efforts of the State and Federal agencies,
except the NRC. Appendix 111.8 provides an itemized
chronological listing of the response actions in moredetail.
b. Emergency Notifications

I n accordance with the NRC-approved plant
emergency plan, the Shift Supervisor, after declaring
99 5

been a release of radioactivity to the containmentbuilding, but that no radioactivity had been detected
off site. At 10:55 a.m., after the NRC announcement,
Pennsylvania Lt. Governor Scranton held a press
conference based upon preliminary information hehad obtained on the accident from Gary Miller at the
TMI Unit 2 control room. He announced that theState had been informed of an "incident" at TMI-2,
but that "everything is under control" and "there is
and was no danger to public health and safety." Hementioned that there had been "a small release ofradiation to the environment." 5
The AMS/NEST from Andrews AFB arrived at
the Capital City Airport near Harrisburg at 1:30 p.m.
and established an operations center in the airport
manager's office. The team's aerial radiation measurement equipment arrived later, enabling the teamto start making aerial surveys of radiation levels in
the area around the plant that afternoon. A Coast
Guard helicopter brought the RAP team from
Brookhaven, landing at the Capital City Airport at
2:30 p.m.
After the initial flurry of notifications and reactions, and based upon the sketchy information obtained from the plant, the State and Federal agencies seemed to reflect that the situation at the TMI
plant was under control, or soon would be, and that
there was no real danger to the local populace.
Other than those immediately involved (that is, the
NRC and DOE among the Federal agencies, and thePEMA and BRP among the State agencies) government agencies adopted passive observer roles.
As the day wore on, it became increasingly apparent that the core had suffered much more damage than the plant operators had originally thought.
Difficulties in putting the plant into a cold shutdown
condition were being encountered. Moreover, radiation releases continued; these were believed to becaused primarily by radioactive gases escaping
from spilled water on the floor of the auxiliary buildi ng.
During Wednesday afternoon, press conferences
held by Jack Herbein of Met Ed at 1:15 p.m. and by
Lt. Governor Scranton at 4:30 p.m., as well as apress release issued by the NRC Headquarters at
5:00 p.m., all indicated that the reactor was undercontrol and, while some radioactivity had beenreleased off site, it posed no real hazard to the local
populace. However, State officials had become
suspicious that Met Ed was not telling them thecomplete story. Lt. Governor Scranton told the reporters at his press conference that Met Ed had"given you and us conflicting information." 6This technical situation continued through all ofThursday, March 29. During the day, DOE sent additional RAP teams from the Pittsburgh Naval Reac-

Aerial Measurement System/Nuclear Emergency
Search Team (AMS/NEST) at Andrews Air Force
Base in Maryland on standby alert.
A telephone call from the NRC Region I office tothe TMI Unit 2 control room at 7:50 a.m. provided
the first notice of the plant emergency to the NRC.
The Region I office immediately activated its Incident
Response Center and called the NRC Headquarters
i n Bethesda, Maryland. The NRC Headquarters activated its Incident Response Center at 8:05 a.m.
and then spent about one hour alerting the NRC
Commissioners and various staff members about
the accident. By 9:30 a.m. the NRC had alerted theWhite House Situation Room and appropriate Houseand Senate staffs. 4
At 9:02 a.m. the Associated Press released a national bulletin stating there had been an accident atThree Mile Island and that a General Emergency
had been declared, but that no details were available. This was the first public notification of the accident.
Meanwhile, for a brief period between 7:45 a.m.
and 8:20 a.m. on Wednesday morning, PEMA
placed the residents of Brunner Island andGoldsboro, in York County downwind from theplant, on evacuation alert. PEMA cancelled the alert
at 8:20 after plant personnel had determined that noradioactivity was escaping from the plant buildings
and BRP had concluded there was little or no potential for radiation leakage from the plant.
The NRC Region I office sent two teams of inspectors to the TMI site. These teams both arrived
at the Unit 1 control room by 11:00 a.m. on Wednesday morning.
Beginning at about 10:20 a.m. on Wednesday, radiation monitoring teams from the plant began
detecting increased radiation levels on the Three
Mile Island site outside the plant buildings. Theseradiation levels continued to increase during theday. Offsite readings downwind from the plantremained low. In response to these radiation readings and because there was a likelihood that small
radioactive releases from the plant would continue,
the NRC requested DOE to move the AMS/NEST
from Andrews AFB to the site area, and the StateBRP requested the assistance of a RAP team from
Brookhaven.
c. Initial Emergency Response
The NRC issued a press release at about 10:30
a.m. on March 28 confirming reports of an emergency situation at the TMI site. The press release stated that primary coolant water had been released
i nto the containment building and that there had
99 6

consultations between the Governor and NRC
Chairman Hendrie, as well as many other individuals.
The Governor had even discussed the partial evacuation with President Carter.
The President requested that Harold Denton go
to the site immediately to act as a central point ofcontact and as the President's personal representative with regard to technical matters concerning theplant status and the potential for radiologicalreleases.
That afternoon, at 2:00 p.m., a meeting of all the
key Federal agencies was held in the White House
Situation Room. Jack Watson, Assistant to the
President for Intergovernmental Affairs, chaired themeeting and assumed the lead role for the WhiteHouse in directing the Federal agency response effort. During the meeting, a decision was made tosend two people to the site: Robert Adamcik, thePhiladelphia Regional Director of the Federal Disaster Assistance Administration (FDAA), to coordinate
the logistical aspects of the Federal agency
response efforts; and John McConnell, Assistant
Director for Plans and Operations of the Defense
Civil Preparendess Agency, to assist the State with
evacuation planning. Following the meeting, Jack
Watson called Governor Thornburgh to advise himthat Adamcik and McConnell were coming in addition to Denton. Watson assured the Governor that
there would be no Federal takeover and that
Federal personnel would maintain a low profile.
Denton and his staff arrived on site by Presidential helicopter from Bethesda at approximately 2:00
p.m. on Friday afternoon. McConnell arrived in Harrisburg from Washington at about 5:30 p.m. Adamcik and his staff arrived in Harrisburg from Philadelphia at about 11:00 p.m.
At 12:40 p.m. on Friday, Roger Mattson at the
NRC office in Bethesda called Chairman Hendrie toreport that the staff estimated that there was a
1000-cubic-foot hydrogen bubble in the reactor
vessel, at a pressure of 1000 pounds per squareinch. Because of the uncertain and unanalyzed
status of the reactor, Mattson recommended thatpeople within a 10-mile radius be evacuated. Chairman Hendrie discussed the reported hydrogen bubble during the 2:00 p.m. meeting in the White House
Situation Room and stated that an evacuation of up
to 20 miles from the plant might be necessary while
the plant technicians coped with the problem. At
about 3:45 p.m. Chairman Hendrie called Governor
Thornburgh and suggested that in view of the hydrogen bubble problem, the Governor should place
the State emergency plan officials on alert status.
At 4:00 p.m. a UPI wire quoted Dudley Thompson of
the NRC in Bethesda as saying that a core meltdown could occur within a few days. At about thetors Office and an AMS/NEST from Las Vegas tothe site to assist in the radiological monitoring effort.
A team of technicians from the NRC Headquarters
also arrived on site during the day. Offsite radiation
monitoring efforts revealed radiation levels only
slightly above the natural background level.
Thursday evening Governor Thornburgh held apress conference during which he stated his belief
that there was no cause for alarm, no danger topublic health, and no reason to disrupt daily routines. However, he noted the conflicting informationthat had been received, and stated that the situation
appeared to be under control, but it was importantfor people to remain alert and informed.
d. Expanded Response After Friday, March 30
During Thursday night and early Friday morning,plant operators conducted several brief venting
operations to relieve the pressure in the reactor
coolant makeup tanks by transferring the gases inthem to the waste gas decay tanks. Leaks in thepiping system connecting these tanks allowed someof the radioactive gases to escape, however, causi ng bursts of radioactivity to be released to the atmosphere during each venting operation. By approximately 7:00 a.m. on Friday morning, pressurei n the makeup tanks had again increased and, at
7:10 a.m., the unit Operations Chief and the Shift
Supervisor jointly ordered resumption of the gastransfer from the makeup tanks to the waste gas
decay tanks; they instructed the operators to leave
the transfer piping line open to allow for a continuing
gas transfer. They also ordered a helicopter aloft to
make a radiation survey over the plant during thegas transfer operation.
At 8:01 a.m. the team in the helicopter measured
a radiation level of 1200 mR/h at an altitude of 600
feet above sea level, 130 feet above the Unit 2 auxili ary building vent stack. The helicopter then flew
l ower in an attempt to better define the source ofthe measured radiation. The radiation level decreased to 600 mR/h as the helicopter descended
and, when the helicopter returned to the original altitude of 600 feet, the team found no further high radiation readings.
Plant personnel reported the 1200-mR/h reading
to both PEMA and the NRC. This set off a chain of
events, described in detail in the "Sheltering and
Evacuation Advisories" section, that culminated in a
sheltering advisory issued by the Governor at 10:25
a.m. for all persons within 10 miles of TMI, and an
evacuation advisory by the Governor at 12:30 p.m.
for pregnant women and young children within 5
miles of TMI. These advisories were issued after
997

same time, McConnell of DCPA called Henderson of
PEMA to advise him that he (McConnell) was coming to Harrisburg. Based on what he had heard
from Chairman Hendrie during the earlier WhiteHouse meeting, McConnell recommended that
PEMA start working on plans for evacuation of thearea within 20 miles of TMI.
At approximately 10:00 p.m. Friday, Governor
Thornburgh and Denton held a joint press conference. On the basis of information obtained from
Denton, the Governor announced his decisions that:(1) no evacuation order was necessary at that time;(2) his earlier recommendation that pregnant womenand preschool-age children leave the area within 5
miles of the plant would remain in effect at least until
Saturday, March 31; and (3) his recommendationthat people within 10 miles of the plant take shelter
would expire at midnight Friday. 8
The Federal agency response swung into highgear on Friday following the agency meeting at theWhite House. The DCPA sent planning personnel
and operators with radios to assist the State andthe counties with evacuation planning. Adamcik andhis FDAA staff went to Harrisburg to coordinate theFederal agency response effort. The DOE significantly increased the radiological monitoring efforts it
had begun Wednesday. HEW sent personnel toparticipate in the radiological monitoring and arranged for procurement of potassium- iodide, a thyroid blocking agent. EPA initiated a comprehensive
environmental monitoring program in the areaaround the TMI plant. The DoD provided air andhighway transportation services to move special
equipment to the site in support of the TMI plant
operations and, in conjunction with the Red Cross,began planning for furnishing and equipping masscare facilities and for providing special transportation for the evacuation. The DOT acted as a consultant in arranging for transportation for potential
evacuees.
The Boise Interagency Fire Center of Boise,
I daho, at the request of the NRC, furnished communications equipment and radio operators to assist
i n the radiation monitoring efforts. The U.S. Postal
Service identified vehicles to be available to assist in
the evacuation. The National Oceanic and Atmospheric Administration provided routine weather forecasts and moved specialized teams and equipment
to the site to provide improved meteorological data
to DOE. The Consolidated Rail Corporation (CONRAIL) arranged for special trains to handle evacuees. At the request of the NRC, the National Bureauof Standards furnished lead bricks for use at theplant and provided data to help analyze the hydrogen bubble problem, and the National Aeronautics
99 8

and Space Administration furnished the services ofa consultant to help Met Ed solve the problem. The
U.S. Department of Agriculture, on its own initiative,ordered all Federal meat and poultry packing plants
within 5 miles of TMI to cease receiving and shipping produce.
Also at the State level, emergency response actions went into high gear on Friday, March 30. The
PEMA Emergency Response Center began operations on Friday morning; emergency response
teams from concerned State agencies were in attendance. The Pennsylvania State Police installed aportable radio base station at the TMI observation
center to provide a radio link with PEMA in Harrisburg. Later Friday afternoon the State Police set up
a mobile command post near the observation centerand increased their patrols that evening to preventl ooting of evacuated dwellings. The National Guardcalled selected officers to State active duty on Friday and began preparing plans to assist in a fullscale evacuation. The Pennsylvania Department ofTransportation began planning to assist in evacuations. The Pennsylvania Department of Agriculture
issued a recommendation through the Governor'spress office that farmers get their animals indoors
and put them on stored, protected feed.
The American Red Cross in Washington decided
that the possible evacuation would be beyond thecapabilities of its local chapters, so it designated its
Eastern Field Office to coordinate planning for themass care facilities that would be required.
Before March 28 emergency planning covered a
5-mile area around Three Mile Island and involved
three counties: Dauphin, York, and Lancaster; prior
to the accident, each county had already preparedemergency plans for its area within 5 miles of theplant. On Friday, however, following the NRC
recommendation of a 10-mile evacuation, PEMA requested evacuation planning for a 10-mile radius,
which concerned four counties. Later that day, after
Denton had briefed the Governor, PEMA expanded
the evacuation planning radius to 20 miles and late
Friday and early Saturday issued instructions to thiseffect to the six counties affected by the change.
These decisions to extend evacuation from a 5mile zone to a 10-mile zone, and then to a 20-milezone introduced entirely new dimensions to thecounties' emergency planning operations. The existing 5-mile evacuation plans could not simply be
expanded to become 20-mile plans because more
people and more institutions were affected andcounties that were outside the 5-mile zone were included in the 20-mile zone. As a result, the affected
counties had to initiate the 20-mile planning almost
from scratch. A frantic planning effort took placeto 12 days and that there was ample time to correct
the problem. He stated his belief that there was noi mminent danger. At a later joint press conference
on Saturday night, both Governor Thornburgh and
Denton attempted to allay public fears about a hydrogen explosion.
On Sunday afternoon at about 1:00 p.m., thePresident and Mrs. Carter arrived at the Harrisburg
airport enroute to visit the TMI site. Denton briefed
the President's party at the airport. At the time,
Denton was still receiving conflicting advice about
the hydrogen bubble from his staff. Some persisted
in their belief that an explosion was possible, whileothers argued that it could not occur. The
President's party toured the plant and the President
later held a brief press conference during which heavoided characterizing the prognosis of the accident, since the seriousness of the hydrogen explosion problem was not known. The President also
did not discuss the possibility of an evacuation, but
he did emphasize that the crisis was not over andhe urged people to remain alert. Though the
President was unable to report that the crisis was
past, his visit to the site did much to abate public
fears of imminent catastrophe.
Later Sunday, on the basis of its own calculations
and the advice of experts around the county, the
NRC staff in Bethesda concluded that oxygen could
not accumulate in the reactor vessel. Thus, aflammable mixture of hydrogen and oxygen could
not be present in the reactor vessel and there wasno danger of an explosion. This conclusion was nottransmitted to the Governor or to the public until
Tuesday afternoon, although late Monday morning
Denton indicated that the oxygen buildup in the
bubble was based on very conservative calculations. The people in the area of TMI-2 went to bed
Sunday evening with the feeling that catastrophe, if
not imminent, was still possible although, in view of
the President's visit, perhaps the danger was not as
real as it had seemed.

during the 2-day period from early Saturday morni ng to early Monday morning, April 2. Several Stateand Federal agencies provided significant assistance to the counties during this planning effort.
PEMA, DCPA, the State Police, the National Guard,
the State Department of Health, and the State
Department of Transportation offered valuable assistance. After the hydrogen bubble had been identified in the reactor vessel on Friday, Met Ed began
operating the plant in a manner designed to allow
the hydrogen gas to escape from the reactor vessel
into the containment building. By Saturday morning,at a press conference in the American Legion Hall in
Middletown, Jack Herbein of Met Ed was able to announce that efforts to reduce the size of the bubble
were apparently meeting with success. He conveyed the impression that plant conditions werestable and that the plant was being brought undercontrol. Almost immediately after Met Ed's press
conference, near noon on Saturday, Denton independently held a press conference in the Middletown Borough Hall. He suggested that, contrary toHerbein's assessment, the crisis was not over andwould not be over until the reactor was completely
shut down. He affirmed his belief, however, that thehydrogen bubble presented no immediate danger ofan explosion. He could not confirm the bubble
shrinkage claimed by Met Ed, inasmuch as the NRC
staff in Bethesda were still examining the data.
At this point, however, there was considerable
concern among the NRC staff that oxygen as wellas hydrogen was being generated within the reactor
vessel and that, in time, an explosive mixture of hydrogen and oxygen would be attained. The staff attempted to calculate when an explosive condition
might be reached. During a 2:45 p.m. press conference in Bethesda, Chairman Hendrie admitted that
evacuation from around the site might have to beconsidered as a prudent precautionary measure, but
he stated his belief that it would be some time before there was any possibility of a flammable condition.
Saturday night, at 8:23 p.m., Stan Benjamin of
the Associated Press put out a bulletin, cleared by
NRC officials in Washington, that warned that thehydrogen bubble showed signs of becoming potentially explosive. He followed this shortly with asecond bulletin attributing to an unnamed NRC
source a statement that the bubble could explodewithin 2 days.
Those press releases caused a near panic in thearea around the plant. At 9:00 p.m. Saturday Denton held an impromptu press briefing in Harrisburg
in response to the bulletins. He said that the hydrogen bubble would not become explosive for from 9

e. Events After Sunday, April 1
By Monday morning, April 2, the emergency
coordinators in the six "risk" counties had reasonably well-detailed evacuation plans laid out; refinement of the plans continued for the next few days.
They had planned evacuation routes and hadphased the evacuation to avoid congestion. The
risk county officials had coordinated evacuationplans, at least minimally, with designated host county officials, and the host counties were well along in
obtaining potential mass care facilities. Host county
999

officials, with Red Cross assistance, developed
plans to staff and stock the mass care facilities.
The risk county officials had arranged for specialtransportation assistance (from military ambulances,for example) to assist in evacuating hospitals andnursing homes. Five National Guard battalions anda headquarters unit were ready for call-up to State
active duty; they stood by to assist local authorities
i n the evacuation efforts and to provide security forthe evacuated area.
At 11:15 a.m. Denton held a press conference in
Middletown to announce that fuel temperatures continued to drop and that the hydrogen bubble had
dramatically decreased in size (although the NRC
technical support staff was still checking the calculations). He acknowledged that earlier reports regarding a possible hydrogen explosion inside thereactor vessel had been based on assumptions thatwere "too conservative" regarding the oxygen generation rate. Finally, he stated that the plant was
about to start using the hydrogen recombiner toreduce hydrogen concentration in the containmentbuilding. By Tuesday afternoon at 2:40 p.m., Denton was able to announce at a press conference
that he no longer considered a hydrogen explosion
to be a significant problem because of the tooconservative numbers that had been used to calcul ate oxygen generation rates, because the hydrogen
bubble had been eliminated from the reactor vessel,and because the hydrogen recombiner was reduci ng the hydrogen concentrations in the reactor containment building.
Federal agency response to the accident continued. On Monday DCPA sent additional staff
members to Pennsylvania to assist the host counties in planning for care of evacuees. DCPA also
shipped 6000 low-range dosimeters, capable ofmeasuring radiation doses in the millirem range, toPennsylvania for use by emergency workers in theplant area.
On Sunday FDAA had begun to hold daily coordination meetings with the participating Federal agencies. These meetings, held in Harrisburg, served as
the clearinghouse for planning protection and evacuation of the populace. In addition, FDAA's Adamcik
became the principal contact point for the NRC personnel on site in obtaining materials and equipment
needed to support the technical operations at TMI.
Adamcik provided daily reports to the White House,through FDAA Headquarters, summarizing the activities of all Federal agencies. DOE had begun to
hold meetings of State and Federal monitoring
teams each day at 5:00 p.m., starting on Friday,
March 30, to consolidate the radiological measurement data accumulated during the day and to plan

the next day's activities. These meetings were held
throughout the period during which DOE coordinated the radiological monitoring data for the State.
The reactor remained relatively stable during theweek; temperatures in the fuel element channels
slowly decreased. On Saturday, April 7, at about
1:25 p.m., the reactor coolant pump that had been
circulating the water through the reactor primarysystem stopped operating and had to be replacedwith a sister pump, which was started and in operation within 2 minutes. Other than causing a slightshift in the pattern of thermocouple readings for fuelelement channels, the change of pumps did not affect the cooling operation.
Denton held additional press conferences during
the week, but they grew more and more routine. Finally, on Monday, April 9, at 3:00 p.m., 13 days after
the accident began, Governor Thornburgh held a final press conference regarding the TMI accident.
Thornburgh stated that he had spoken with Chairman Hendrie and that he had met with Denton,
Adamcik, Lt. Governor Scranton, and other State
officials. On the basis of the information and adviceof these persons, he had decided to end all previous recommendations, advisories, and directives:pregnant women and preschool-age children could
safely return to their homes; schools in the TMI area
would reopen on Tuesday, April 10; State offices
would return to business as usual; and emergency
preparedness forces could shift from their full alert
to an on-call status. Governor Thornburgh announced that he had been assured by State Department of Environmental Resources and State Healthofficials that the milk and drinking water of central
Pennsylvania posed no residual threat to publichealth. The emergency was over.
f. Long Term Recovery Phase
Following the Governor's press conference on
April 9, activities at and around Three Mile Island
entered a long term recovery phase.
The plant has operated with natural circulation of
coolant since April 27. Eventually the cleanup
crews will have to enter the containment building
and remove the damaged fuel elements from thereactor. Such activity, however, is months in the future. I n the meanwhile, Met Ed has undertaken
cleanup operations of the auxiliary and fuel handlingbuildings and other plant facilities that became contaminated during the accident. Final cleanup andrestoration of the plant to commercial service are
estimated to be several years away and will costseveral hundreds of millions of dollars. At the time1000

this report is issued, no decision has been announced as to the ultimate plans for the TMI-2
facility.
On April 13, 1979, Jack Watson sent a memorandum from the White House to the Secretaries of
Health, Education, and Welfare (Califano) and Energy (Schlesinger) and to the Administrator of the Environmental Protection Agency (Costle), designating
the Environmental Protection Agency as the leadFederal agency to continue the environmental radiol ogical monitoring effort in the TMI vicinity during thefinal stages of plant shutdown and the start of thecleanup effort. He requested that HEW and DOE
continue some of their radiation monitoring efforts
and furnish the data obtained to the EPA operations
center for inclusion in a report to be prepared by
EPA for submission to the President's Commission
on TMI. Federal monitoring activities around theplant will continue until cleanup of the damaged
reactor is completed.
On April 19, 1979, Jack Watson sent a memorandum from the White House announcing that he had
designated Thomas C. Maloney, Chairman of the
Mid-Atlantic Federal Regional Council, to serve as
the lead Federal official responsible for coordinating
Federal response to the TMI accident. 9 I n thememorandum, Watson confirmed that the NRC
would "continue to have full on-site responsibility atThree Mile Island," and that EPA would "continue tohave the lead for all direct federal activities pertaini ng to environmental monitoring." Watson assigned
specific responsibilities to Maloney, including "...assuring effective communication within the Federal
government and with the Governor and State officials, identification of problems requiring federal assistance, and monitoring the effectiveness and quality of federal responses."On April 27, A. Vernon Weaver, Jr., Administratorof the Small Business Administration (SBA), approved the request of Governor Thornburgh to declare the five-county area including Cumberland,
Dauphin, Lancaster, Lebanon, and York Counties an
economic dislocation area. The SBA establishedspecial offices in Harrisburg, Lancaster, York, andMiddletown to handle claims from local businesses.
The program was designed to run through December 1979, but the SBA closed the Middletown
office about the end of June and the other offices in
October because of the small number of claims
submitted.
Due to the fact that any damage to human healthwould first be discernible in newborn or stillborn infants, HEW's Region III office funded a State Department of Health study beginning immediate data collection on pregnancy outcomes. The Federal
100 1Center for Disease Control in Atlanta, Georgia, andthe National Institutes of Health authorized the State
Department of Health to incur up to $300 000 incosts to complete a detailed population census of all
persons within 5 miles of TMI. Federal personnel,
especially from the Center for Disease Control and
the Public Health Service, provided extensive onsite
technical assistance to the State Department of
Health for this effort. Data collection for the census
was virtually complete by July 15, 1979. This
census registry will be used for any future healthstudies of the population. The National Institute of
Mental Health has designed and is now funding amental health survey to study the psychological impacts of the TMI crisis.
The Defense Civil Preparedness Agency, now apart of the Federal Emergency Management Agency(FEMA)1° and the Nuclear Regulatory Commission
designed a joint survey to study emergency
response and behavior of the population affected by
the TMI accident. Federal emergency agencies
have been reviewing the adequacy of their own
preparedness and working with State and local officials to improve the emergency planning andpreparedness at the State and local levels.
Several Federal agencies (Department of Commerce (DOC), HUD, DOE, and the Community Services Administration) are funding a comprehensive
study by the Governor's Office of State Planningand Development of the socioeconomic impacts of
TMI. The Commonwealth's socioeconomic study
focuses on the impacts of TMI in the following
areas: commercial and industrial production andemployment, agricultural production and commodity
consumption, food processing industries, tourism
and travel, new residential and commercial construction, residential real estate activity, community
development, local governmental budgets, State andlocal revenues, and insurance claims associatedwith the accident.
The Mid-Atlantic Federal Regional Council has
coordinated Federal assistance relative to theeconomic impacts of TMI in the Harrisburg area andi s prepared to take action to mitigate adverse
economic impacts if necessary.
3. FEDERAL AND STATE AUTHORITIES ANDRESPONSIBILITIESa. Introduction
Statutes, formal agreement, and tradition govern
the response of Federal, State, and local government organizations to a peacetime nuclear emer-gency such as that presented at Three Mile Island.
This subsection of our report explores this composite framework of government as it stood on March
28, 1979. In so doing, we wish to provide the background necessary to understand how government
agencies came to perform critical official response
functions during the emergency and how the
weaknesses and strengths of the framework affected the response to the accident. The details of theFederal and State responses to the accident andthe expanded evacuation planning which took place
during the accident appear in other parts of thisSection III.C.
By vesting in the President the executive powerof the Federal Government and naming him
Commander-in-Chief, Article II of the United States
Constitution authorizes the President to command
the Nation during peacetime civil emergencies aswell as in times of military crisis abroad. A similar
executive power to lead a State in times of domestic crisis resides in the Governor of each State of
the Union and receives formal recognition in eachState's constitution. The President and the Governors have at their disposal numerous organizations,equipment, and expertise to aid them in responding
to an emergency.
At the same time, tradition dictates that local
communities, from town to county, retain primary
responsibility for planning emergency proceduresand for carrying out those procedures in an actual
crisis. The premise is that an evacuation teamcomprised of local citizens will better know whom toaid and by what route to evacuate, for example,
than will a team of strangers to the stricken region.
Between these extremes of power and capability lie
many official responsibilities and authorities for
managing an emergency. These manifold duties independently create a further responsibility: coordination of Federal, State, and local roles in respondi ng to a crisis.
This subsection outlines the Federal and Stateauthorities and responsibilities as they stood on
March 28, 1979, for responding to an accident at a
fixed nuclear facility. It describes how these authorities and responsibilities were documented prior to
the accident, and how they affected the response to
the accident.
b. Federal Authorities and Responsibilities
As stated, the President derives his broad power
and responsibility to lead the Nation during adomestic nuclear crisis from Article II of the UnitedStates Constitution. Congress has enacted several
statutes to enable the President to perform his role.
In 1950 Congress passed the Federal Civil Defense Act, 50 U.S.C. Sections 2251 et seq., underwhich the Defense Civil Preparedness Agency(DCPA) 11 was established as part of the Defense
Department. Though this Act was designed to copewith emergencies arising from an enemy attack, andthough the section of this Act that provided DCPA
with emergency powers during a civil defense emergency has lapsed, the Act nonetheless establishes
an emergency management mechanism available for
executive use during a domestic nuclear accident.
As will be explained below, the President is authorized to use the DCPA in any kind of civil emergency.
More recently Congress passed the Disaster Relief Act of 1974, 42 U.S.C. Sections 5121 et seq.,
which places a broad array of emergency measuresat the disposal of the President and the Federal
agencies to supplement State operations. The Act
makes access to these measures contingent upon a
Governor's request and the President's subsequentdeclaration that a major disaster has occurred. The
Act circularly defines a "major disaster" as "anyhurricane, tornado.... fire, explosion, or other catastrophe in any part of the United States which, inthe determination of the President, causes damageof sufficient severity and magnitude to warrant
ma12
Thoughj or disaster assistance under the Act...."
many of the measures authorized by the Act areoriented toward the type of disasters enumerated in
the definition quoted above, i.e., a severe tornado orfire, the measures would be appropriate also in theevent of a severe nuclear accident.
The Disaster Relief Act provides, for example,
that agencies may loan or donate equipment, supplies, and personnel to a stricken area during an
emergency, 13 or may make contributions to Stateand local governments to help rebuild an area afteran accident. 14 The Act authorizes the President
generally to provide a disaster-torn area with suchother assistance under the Act as he deems appropriate 15 to this end, it explicitly licenses the
President to use the services of the DCPA.
The Disaster Relief Act of 1974 also permits thedevelopment of contingency plans for dealing with
nuclear catastrophes, including an accident at a nuclear powerplant. 16 Toward this end the President
has issued three Executive Orders (Executive Orders 11051, 11490, and 11725) which require theFederal Preparedness Agency (FPA), an emergency
planning agency within the General Services Administration, to (1) coordinate and develop policy for
emergency planning and preparedness amongFederal departments and agencies, (2) prepare non-100 2

military plans and preparedness programs within theFederal Government, (3) stimulate State and local
participation in emergency preparedness, and (4)coordinate Federal and State involvement in emergency preparedness. The Executive Orders also
require Federal agencies to develop peacetime nuclear emergency operational response plans.
FPA initiated the Federal planning effort forpeacetime nuclear emergencies called for by these
Executive Orders in April 1977, by issuing a document entitled "Federal Response Plan for Peaceti me Nuclear Emergencies (Interim Guidance)"(FRPPNE). FRPPNE, as issued in April 1977, was
not a response plan but was intended to accomplish
four objectives: (1) provide policy and interim guidance to Federal agencies for the development, review, and maintenance of Federal plans and capabilities for responding to peacetime nuclear emergencies; (2) facilitate complete and coordinatedFederal planning for all peacetime nuclear emergencies; (3) provide a basis for compatibility between
Federal and State plans; and (4) identify responsibility for implementing and coordinating the efforts ofFederal agencies responding to peacetime nuclear
17
emergencies.
The FRPPNE Interim Guidance directed the Nuclear Regulatory Commission, the Department ofEnergy, the Federal Disaster Assistance Administration, the Defense Civil Preparedness Agency, and(for incidents of domestic terrorism) the Departmentof Justice, to prepare operational response plans for
specific types of nuclear emergencies. More thantwenty other Federal agencies were designated toprovide planning and operational support to these
five primary agencies. The FPA encouraged theagencies to make maximum use of existing
response plans in preparing the plans required by
the April 1977 guidance. The FPA was responsible
for overall coordination and direction of the FRPPNE
planning effort.
In March of 1979, neither FRPPNE in its final form
nor the five operational response plans called forunder the April 1977 Interim Guidance had been
completed. However, one Federal response plan forpeacetime nuclear emergencies, the Interagency
Radiological Assistance Plan (IRAP), in existence
when FPA issued its Interim Guidance, continued in
effect at the time of the accident at TMI.
IRAP is a Federal interagency agreement
developed in 1961 to provide a means for using
Federal resources for radiological assistance in theevent of a peacetime nuclear emergency. Thirteen
Federal agencies participate in the agreement. IRAPi s intended to optimize the use of existing Federal
facilities and capabilities and to encourage develop-

ment of State and local plans and capabilities tocope with radiological incidents. It obligates its signatory agencies to make available their resources
for development of an integrated Federal radiological assistance capability and for responding to a radiological emergency, subject to prior commitments
to fulfill the agencies' primary responsibilities. It also
obligates the Federal agencies to make their radiological response training capabilities available to
IRAP anticipates
State and local authorities.
Federal, State, and local cooperation, and reciprocity with State and local governments during an emergency.
The Department of Energy (DOE) is assigned
responsibility in IRAP for administration, coordination, and implementation of the radiologicalresponse efforts covered by the Plan. In support ofI RAP, as well as its other responsibilities, DOE maintains a national Emergency Operations Center atGermantown, Maryland, and eight Regional Coordinating Offices. Typically, requests for assistanceunder IRAP are made by a State or local agency toa DOE Regional Coordinating Office. That officethen calls upon the services of another agency, or
dispatches a Radiological Assistance Plan (RAP)
team, a DOE capability, to the locality, depending on
the nature and extent of the request. Prior to March
28, 1979, DOE had responded to many minor radiol ogical incidents, mostly transportation accidents involving radioactive materials, which did not requireassistance from more than one signatory agency.
At the time of the TMI accident, the interagency
coordination aspects of IRAP had never been tested.
I RAP is not a plan, but a general inventory of radiological monitoring capabilities, both national andregional, of the 13 participating Federal agencies
and is also a compilation of useful operational data,such as the locations and telephone numbers of the
DOE Regional Coordinating Offices. IRAP defines
neither the conditions under which its agency obligations will be activated nor who will bear the financial responsibility for the resulting response.
c. Implementation of Federal Authorities andResponsibilities During the TMI Accident
During the first 2 days of the accident at TMI,
DOE was the only Federal agency, other than the
NRC, to respond officially to the accident. DOE's
radiological assistance to the NRC was not requested specifically under IRAP, although the NRC wasaware of IRAP and of DOE's lead agency role underthat agreement. The DOE support of the NRC was
100 3

carried out under the interagency agreement
between the two agencies developed following thecreation of the NRC ("Agreement Between the U.S.
Energy Research and Development Administrationand the U.S. Nuclear Regulatory Commission for
Planning, Preparedness and Response to Emergencies," March 8, 1977). The DOE support of theCommonwealth of Pennsylvania was automaticallyunder the aegis of IRAP. Because DOE was the
only Federal agency responding at that time and because DOE's relationships with both the NRC andthe State were clear, there was no requirement forFederal interagency coordination.
With the perceived escalation of the emergency
on Friday morning, March 30, several additional
Federal agencies, notably the Environmental Protection Agency and the Department of Health, Education, and Welfare, initiated their own involvement in
TMI. Because FRPPNE had not been completed,the functions that these other agencies should have
performed and the mechanism for coordinating theoverall Federal response was not clear. As a result,each agency independently initiated the radiologicalmonitoring or other assistance programs that each
was capable of providing. IRAP was not used tocoordinate the Federal radiological monitoring activities because the assistance of the other signatory
agencies that responded was not requested by
DOE, the NRC, or the State under IRAP. Though
I RAP was not fully invoked during the accident, thei ndividual responses of the TRAP signatory agencies
were largely consistent with the commitments they
had made in IRAP.
The lack of clear mechanisms for coordinating
the Federal response under FRPPNE or IRAP and
the fact that the State had not requested a disasterdeclaration resulted in White House intervention on
Friday afternoon, March 30. The White House did
not undertake a command function; it did not direct
the Federal response to the accident. It did attempt
to coordinate the Federal response and ensure
Federal and State coordination by arranging meeti ngs of the involved Federal agencies to discuss
what was being done. The White House also designated a lead Federal official for the TMI off site
response: Robert Adamcik, the Director of theFederal Disaster Assistance Administration's Philadelphia Regional Office. John McConnell of the Defense Civil Preparedness Agency was designated toassist the State in evacuation planning, and Harold
Denton of the NRC as the President's personaltechnical representative on site.
Adamcik's responsibilities did not extend to coordination of the extensive Federal radiological monitoring effort that had begun in the area by Friday
evening. 18 This gap was filled Friday night during ameeting in the Harrisburg area that was attended by
the NRC, DOE, EPA, HEW, and State BRP officials,
a meeting at which Thomas Gerusky, the Director of
BRP, asked DOE to coordinate all State and Federal
radiological monitoring.
Because Governor Thornburgh had not requested that the President make a disaster declaration
for TMI, the Federal response authorized under theDisaster Relief Act of 1974 could not officially bemade available to the State. The evidence indicatesthat no disaster declaration was requested by theGovernor to avoid unnecessarily escalating the concerns of the people in the TMI area over the accident. The Governor has stated, however, that hewithheld requesting the President to make such a
declaration because he had been assured by theWhite House that Pennsylvania would receive thesame level of Federal assistance, both during andafter the incident, without a disaster declaration as
they would have received if a disaster had been declared. 19 We believe that the Governor would haverequested a disaster declaration had the Federal
assistance not been satisfactory or had the situation
at the plant deteriorated.
It is unclear what effect, if any, the absence of adisaster declaration had on the Federal response.
Such a declaration would have clarified the authority
under which certain actions were taken and would
have made Federal funds available to the State,after the emergency, to pay for certain extraordinary expenses which were incurred. We uncovered
no evidence, however, that the Federal response
would have been significantly different with a disaster declaration. A disaster declaration probably
would not have resulted in an earlier Federal
response because events on Wednesday andThursday did not lead State officials to believe thata situation necessitating a request for such a declaration had occurred or was likely to occur. Also,
the actions by the White House on Friday accomplished the same Federal coordination and response
as a disaster declaration would have.
On April 13, after the emergency was over, theWhite House took steps to coordinate the long term
radiological monitoring in the TMI area by designating the EPA as lead agency for these efforts, to beassisted by HEW and DOE. 20
d. State, County, and Local Authorities andResponsibilities
Legislation and Statewide Powers

The response plans that the Commonwealth ofPennsylvania had in place on March 28 assigned initial responsibility for directing emergency actions to
100 4

local communities and envisioned that communities
would call upon county and State agencies as theirneeds required. The State's plans acknowledged
State responsibility for coordinating response efforts involving two or more counties and for seeking
Federal assistance when appropriate.
As of March 28 the Commonwealth of Pennsylvania had in effect a Disaster Operations Plan that
had been issued in accordance with the Federal
Civil Defense Act of 1950, discussed earlier, under
the authority vested in the Governor by
Pennsylvania's State Council of Civil Defense Act of1951. 21 The Disaster Operations Plan establishedcertain fundamental principles, local responsibility
preeminent among them, which were to govern thesubsidiary programs that the Plan required. It alsosought to provide a "common basis for joint State
and County/local government operations in natural
disaster ...situations." 22 The plan charged the StateCouncil of Civil Defense with the responsibility forputting the plan into effect.
I n November 1978 the State legislature enacted
the Emergency Management Services Code, 23 repealing the State Council of Civil Defense Act of1951 and other related acts and adding certain provisions relating to emergency management. The
Code established, among other things, the following
emergency responsibilities within the State. First, it
articulated the Governor's ultimate responsibility "formeeting the dangers to this Commonwealth andpeople presented by disasters," 24 and gave him
broad legal powers, apparently contingent upon his
proclamation of a disaster. 25 Second, the Code established the Pennsylvania Emergency Management
Council, which consists of 16 high ranking State officials, including the Governor and the Lieutenant
Governor, to supersede the State Council of Civil
Defense. The Governor has appointed the Lieutenant Governor Chairman of the Council. Under
the Code, the Council was to employ an individual todirect the Pennsylvania Emergency Management
Agency (PEMA), which superseded the staff officeunder the State Council of Civil Defense. It specifically assigned PEMA a new responsibility for
responding to peacetime nuclear emergencies anddirected PEMA to prepare an emergency plan for
the State, to provide technical assistance to Stateagencies and political subdivisions, to monitor the
status of local emergency plans, and to "provide
emergency direction and control 26
of Commonwealthand local emergency operations."
Third, the Code directed and authorized eachpolitical subdivision of the Commonwealth to establi sh a local emergency organization in accordancewith PEMA's overall plan and program and gave
each subdivision the responsibility for local emer-

gency management and recovery and the power todeclare a "local disaster emergency." 27 Each local
emergency management organization was to beheaded by a coordinator and was to prepare, maintain, and keep current a disaster emergency
management plan; establish, equip, and staff anemergency operations center; and provide prompt
and accurate information regarding local disasteremergencies to appropriate Commonwealth officials
and to the general public. Fourth, the Code provided immunity from civil liability, except in cases ofgross negligence or willful misconduct, for persons
engaged in disaster service activities in compliancewith the Code. Finally, it imposed monetary penalties on persons violating its provisions and gave theCouncil power to halt Federal personnel and admini strative funding of any political subdivision found tohave violated the Code.
PEMA and BRP Plans

At the time the Commonwealth's Disaster Operations Plan was developed, the Department of Environmental Resources (DER), not the State Councilof Civil Defense, PEMA's predecessor, was responsible for emergency planning for nuclear powerplants in Pennsylvania. 28 However, in July 1977,
because DER had not completed a State-wide plan
for responding to nuclear emergencies, PEMA included Annex E, entitled "Nuclear Incidents (Fixed
Facility)" in the Disaster Operations Plan. This wasi ntended as a stopgap measure until DER finished
its plan. At about the same time, the Director of
PEMA and the Secretary of DER entered into anagreement which provided that DER would continue
to be the lead State agency in fixed nuclear facility
29
planning.
Annex E addressed in vague terms the relationship of local, county, State, and Federal governments in emergency response; the responsibilities
of county and local governments; the roles of BRP,
PEMA, and other State agencies during a nuclear
emergency; the Federal assistance available to a
State emergency response effort; and listed certain"protective action guides" for use in a nuclear emergency. 30
I n September 1977, 2 months after the appearance of Annex E, BRP issued a "Plan for Nuclear
Power Generating Station Incidents." In this plan
BRP addressed in greater detail the issues raisedby PEMA in Annex E, and added discussions of accident assessment procedures and protective action
options available during a nuclear accident. BRP's
plan was largely consistent with Annex E.
According to these plans, which were both in effect on March 28, 1979, a utility was to give initial
100 5notification of an accident to PEMA. PEMA would
first alert BRP, and then notify other State departments and agencies of the accident. If an emergency were officially declared-and, as we have observed, no emergency was declared during the TMI
accident-PEMA was responsible for several tasks:(1) coordinating State, county, and local emergency
operations; (2) coordinating technical and other assistance extended by Federal and private organizations; (3) relaying information to the counties; (4)operating the State's emergency operations center;and (5) maintaining emergency communications facilities. BRP's tasks were to: (1) establish andmaintain contact with the facility for accident assessment purposes; (2) conduct environmental
sampling and analysis; (3) advise State, county, andl ocal agencies, through PEMA's information network, to take appropriate protective actions; and (4)request radiological monitoring assistance fromFederal agencies, as needed.

These plans also assigned responsibility for particular response efforts during a nuclear emergency
to other State agencies, including the Departmentsof Agriculture, Justice, Transportation, Health, andMilitary Affairs; the Fish and Game Commissions;and the State Police. The plans did not, however,provide for liaison between BRP and the Department of Health or provide for the Department of
Health to be consulted by BRP regarding the needfor protective actions during radiological emergencies.
I n 1978 Dauphin, York, and Lancaster Counties,
on the advice of PEMA, had developed emergency
plans for accidents at TMI, including plans for a 5mile evacuation. While these plans differed greatly
in detail, each generally described public notificationand evacuation procedures to be used in the eventof an accident. None of the localities within 5 milesof TMI had emergency plans specifically for accidents at TMI, although the county directors had
encouraged development of the plans before theaccident. At the time of the accident, the three
counties within 5 miles of TMI had full-time emergency management directors and all but two of thelocalities within the 5-mile area had appointed emergency management coordinators.

Only the notification and communications aspectsof the State plans had been tested prior to the accident. Though the county plans had not been formally tested, the three counties within 5 miles of
TMI had conducted limited evacuations in the past
because of flooding of the Susquehanna River andtherefore had some emergency management experience.

100 6

e. Implementation of State, County, and Local
Authorities and Responsibilities During the TMI
Accident
During Wednesday and Thursday, March 28 and29, the State response to TMI consisted primarily of
PEMA and BRP carrying out their responsibilities
according to the existing plans. Lieutenant Governor Scranton, in his capacity as Chairman of thePennsylvania Emergency Management Council,
served as spokesman for the State and senior State
official handling TMI during those 2 days.
The events of Friday morning heightened concern within the State over the seriousness of theaccident and resulted in Governor Thornburgh taki ng charge of the State response to the accident.
Although this action was not contemplated in Stateplans, it was not inconsistent with the Governor's
authority and responsibility under the Pennsylvania
Emergency Management Services Code. This action had major effects in the areas of decisionmaki ng and communications.
The events on Friday also resulted in officials
within PEMA and many other State agencies and in
the counties planning furiously for an expanded
evacuation, in the middle of the crisis. This action
obviously had not and could not have been anticipated in the State's preaccident planning efforts,
particularly since the NRC had only stressed theneed for such planning in the Low Population
Zone-a distance for TMI of only about 2 miles.
Throughout the crisis, BRP continued to operateaccording to its plan, although on Friday BRP officials found that the expanded Federal presence had
resulted in significantly more radiological monitoring
activities in the area than they had requested. As
was noted before, on Friday evening BRP requested
that DOE coordinate all Federal and State radiological monitoring programs for the State. Although the
BRP plan did not provide for liaison and consultation
with the Department of Health, effective liaison
between the Director of BRP and the Deputy Secretary of Health for Administration took place during
the accident because the Deputy Secretary of
Health had previously worked in DER and knew the
Director of BRP.
During the TMI accident, Governor Thornburgh
did not declare a disaster emergency under thePennsylvania Emergency Management Services
Code. However, on Friday afternoon the Pennsylvania Emergency Management Council was convened. At least part of the reason for this meeting
appears to have been the requirement of Section
7312(d) of the Emergency Management Services

sion and coordination problems as the Federal
response expanded Friday. However, it is clearthat improved Federal plans, in and of themselves, would not have resulted in a substantial
i ncrease in protection of public health and safety
i n the accident at TMI. This is not to say thatsuch plans might not be extremely important in a
fast-moving accident with greater offsite consequences.
2. The TMI accident clearly revealed implementationand coordination deficiencies in IRAP, the only
complete Federal response document at the timeof the accident. These inadequacies could havebeen revealed either by a pragmatic review of theagreement or through appropriate testing.
3. FRPPNE did not provide a guide for Federal
agency response or a mechanism to coordinate
the Federal response because it had never been
completed.
4. The Governor's decision not to request the
President to make a disaster declaration did not
substantially affect either the State or Federal
response. In the absence of a declared disaster,
the actions taken by the Governor and the WhiteHouse on Friday, March 30, assured adequate
Federal and State coordination.
5. The State plans did not formally provide for liaison between BRP and Health authorities or for
BRP's consultation with Health authorities onprotective action recommendations. However,effective liaison between these two organizations
was accomplished during the accident. One reason for this effectiveness was a prior professional relationship of the top officials in each organization.
6. There may be a substantive conflict between theState law (which charges PEMA with "direction
and control of local emergency operations") andthe philosophy of State response as described in
the Disaster Operations Plan (which charges the
local jurisdictions with the basic responsibility forprotection of health and safety). This potential
conflict should be carefully reviewed, and the authority to command and responsibility for protection of citizens in the State should be clearly documented.

Code that when a disaster is determined actually or
li kely to exist, the Chairman of the Council shall callthe Council into session within 48 hours. Although
we are not aware that such a determination was officially made, the escalation of events that morning
could have led the Governor or Lieutenant Governor, or both, to believe that a disaster situation wasli kely to exist.
Finally, though the Emergency Management Services Code attempts to protect Commonwealth personnel from civil liability in carrying out emergency
functions, the constitutionality of this law was being
challenged at the time of our inquiry, though not in a
TMI-related lawsuit. The question of liability could
be an important one and could enter into the thinki ng of a decisionmaker, particularly when consideri ng precautionary protective measures that are
costly to the public and that may prove in retrospect
to have been unnecessary. However, Governor
Thornburgh has stated that the cost of evacuationor the question of liability never entered his mind
during the entire time the possibility of evacuation
existed. 31
f. Findings and Recommendations
The preceding narrative describes the Federal andState authorities for responding to peacetime nuclear emergencies and the status of planning forthese emergencies as of March 28, 1979. It also
briefly describes how these authorities and the existence or lack of plans influenced the Federal andState response to the accident. Since the accident,changes in both the Federal and State planning andresponse programs for peacetime nuclear emergencies have taken place or have been proposed. Because our recommendations build upon thesechanges, several of them will be briefly introduced in
the detailed
recommendations which follow.
Greater details on the Federal changes are presented in Appendix 111.9.
The findings of this section are:1. I n general, while there existed a reasonable
understanding of Federal emergency response
authorities and responsibilities in the event of a
nuclear powerplant accident, there was no effective, coordinated emergency response plan inwhich the operational mechanism and responsibilities of interagency response, coordination, andcommand were clearly spelled out. The lack ofFederal response plans for peacetime nuclear
emergencies probably delayed the Federal
response somewhat and resulted in some confu-

Specific detailed recommendations relating to thedevelopment of State, county, and local emergency
plans are included in Sections III.C.4 and 5.
The detailed recommendations of this section regarding overall authorities and responsibilities are as
follows:
1. On September 16, 1978, Federal Reorganization
Plan No. 3 established the Federal Emergency
1 00 7

Management Agency (FEMA) as the agency
responsible for centralized overall planning andcoordination for Federal agency response to emergencies, including nuclear reactor accidents.
We endorse this action. We believe it is appropriate for FEMA to be the lead Federal agency
for emergency planning and operations for fixed
nuclear facilities because:a. Many of the elements of the emergency
response are common to both nuclear and
and
FEMA,
nonnuclear
emergencies,
through its predecessors, has had lead
responsibility for most emergency response
planning and operations. However, FEMA
can and must delegate specific technicalaspects of planning and response functions
to other Federal agencies such as the NRC,
the EPA, DOE, and HEW, while retaining
overall responsibility and authority.
b. Through its many responses to other manmade and natural disasters, FEMA has anormal operating role that will keep its emresponse
capabilities
sharp,
ergencywhereas another agency like the NRC
would have more difficulty maintaining its
proficiency.
c. The emergency response role should noti nvolve an emotional or philosophical conflict with the normal activities of the organization.
d. To the extent practicable, duplication ofFederal resources should not be encouraged by the assignment of the same
emergency response authorities or responsibilities to more than one Federal agency.

We caution, however, that in the interim, while
FEMA is in the process of developing its capabilities, FEMA must make optimal use of the workthat the NRC has done and is presently doing inproviding guidance to the States and in reviewing
existing State plans.
2. To handle planning and coordination FEMA musthave sufficient authority to generate a timely
response from other Federal, State, and local
agencies. Such authority must recognize the foll owing:a. The NRC has authority over the regulated
nuclear industry and has associatedresponsibilities, including the approval of
the utility licensee's emergency plan andconcurrence in certain aspects of theState's plan. A memorandum of understanding should be prepared between the
NRC and FEMA outlining their respective
responsibilities.

b. Many of the general needs and requirements for offsite emergency response tonuclear powerplant accidents are similar to
those needs and requirements for otherkinds of disasters and should be appropriately meshed with plans for those otherdisasters.
The only unique planning
aspects that must also be incorporated are
the development of radiological protective
action guidelines, criteria as to when theseguidelines should be implemented, therequirements for radiological monitoring andassessment, and the need for technicalassessments and forecasting of plantstatus.
c. The State and local agencies have authority
over their citizens and have associatedresponsibilities.
d. The utility has the basic responsibility forthe safe operation of the licensed nuclear
powerplant.
3. FEMA must develop a comprehensive Federal
response plan for peacetime nuclear emergencies. (At the time of our inquiry, Congress was
proposing in the NRC's fiscal 1980 appropriations
bill (S. 562) the development of a more explicit
description of Federal and State authorities,
responsibilities, and coordination. This bill would
require that within 120 days of enactment the
President, through FEMA, develop a National
Contingency Plan, and that within 6 months the
NRC develop an agency plan.) We recommendthat the national plan developed by FEMA must
i nclude the following, as a minimum.
a. Upgrading of the Federal Response Plan for
Peacetime Nuclear Emergencies (FRPPNE).
b. Upgrading and better coordination with- FRPPNE of the Interagency Radiological
Assistance Plan (IRAP) and the various
agency plans, such as DOE's Radiological
Assistance Plan (RAP).
c. A better description of the resources that
could be expected on a temporal basis fromthe various agencies (e.g., ARAC at LLL,
aerial surveillance capabilities, field laboratories, monitoring equipment, communications equipment, transportation facilities,
personnel, etc.).
d. A clearly established command and coordination relationship among the various
Federal agencies.
e. A category of response short of a declareddisasterwhich
activates
appropriate
response authorities and responsibilities.
4. The proposed NRC appropriations bill (S. 562)
requires that an NRC emergency plan be1008

discharged by PEMA, the circumstances underwhich they would become effective, and theoperational aspects of discharging them.

developed that provides appropriate details for
rapid agency response to reported incidents at
nuclear facilities. Some of these provisions are in
the area of NRC interface with other Federal
agencies. Therefore, the following important factors must be considered in the development of
this plan.

4. SHELTERING AND EVACUATIONADVISORIES

a. The principal focus of NRC emergency
planning efforts must be: (1) establishmentof appropriate accident and consequence
scenarios with attendant probabilities; (2)development of protective action guidelines
and criteria for implementation; and (3)preparation for effective, i ndependent
technical evaluation and forecasting of plantstatus and likely radiological releases.
These factors need to be coordinated with
FEMA, EPA, HEW, and DOE.

During the first week of the nuclear accident atThree Mile Island (TMI), a number of official decisions were made to protect the health and safety ofthe people living near Metropolitan Edison's (MetEd) Unit 2 reactor. These decisions affected almost
three quarters of a million people within 20 miles ofthe plant. They included issuing an advisory to"stay indoors," an advisory to evacuate pregnant
women and preschool children within 5 miles of theplant, and decisions at various times not to order ageneral evacuation. Since the State is the politicalentity that must order its citizens to take protective
actions, most of the following is a discussion of
events as seen from the vantage of the State.

b. The NRC must not plan for independent,
extensive radiological monitoring and assessment capabilities. This is a function of
DOE, EPA, the State, the licensee, and other Federal agencies, as appropriate. In
particular, DOE is already equipped forprompt, large-scale emergency response
and has the built-in advantage of more frequent operational testing of the personnel
and equipment in its day-to-day operations.
Therefore, duplicative Federal resources
would be avoided and a more effective
response likely provided if DOE were formally assigned this function. (The current
version of S. 562 assigns EPA the responsibility for radiation monitoring outside thefacility boundaries, a substantial duplicationof Federal resources. EPA should, however, be the lead agency for the long term assessment of radiological effects, andshould, therefore, have a role in planning forroutine and emergency monitoring. HEW
should have the role of determining theresultant radiological health effects on the
population.)a. Background
By definition, protective actions in a nuclear accident are actions taken to avoid or reduce a
population's exposure to radiation after a reactor
accident. The greater a population's exposure, thegreater the number of damaging health effects, suchas cancer, that can be expected within that population. Accordingly, to decrease the number ofradiation-caused health effects resulting from an accident, government officials may either recommend
or direct that various protective actions be taken.
I n planning for emergency response to a reactor
accident, State and Federal officials commonly consider ordering or advising a population to take thefollowing protective actions: (1) "evacuation," inwhich all or selected categories of persons leaveand stay out of a specified area surrounding theplant; (2) "taking shelter," in which persons remain
i nside a building to minimize their radiation exposure(persons remaining inside receive less radiation thanthose remaining outside); (3) "thyroid blocking," inwhich a drug is administered to prevent the thyroid
gland from absorbing radioactive iodine released
from the plant or contained in contaminated food orwater, thus reducing the radiation dose to the thyroid; and (4) food or water interdiction, in whichcontaminated food or water is prohibited from human consumption. (The last two forms of protective
action will be discussed in more detail in a subsequent section.)

5. Regarding State and local authorities andresponsibilities, there could be a substantive conflict between elements of the State law that authorize PEMA to exert command control over local emergency actions and the portions of thelaw (and the underlying basic philosophy) thatcharges the local jurisdictions with the responsibility for protection of the health and safety of
their citizens. This possible problem should be
carefully considered by the Commonwealth (andother States), and the emergency plan mustclearly describe the command functions to be1009

Following the accident on March 28 much official
effort was devoted to measuring the levels of radiation and radioactivity in the TMI area. Radiologicalmonitoring teams made measurements close to theplant, at distances 15 or 20 miles or more from theplant, and at many points in between. The results ofthese measurements were used by government officials to estimate the risk to persons in the area andto decide which, if any, protective actions should be
advised or ordered to reduce the estimated risk of
exposure.
As an aid in deciding when to take these protective actions, in September 1977 the Pennsylvania
Emergency Management Agency (PEMA) issued thePennsylvania Disaster Operations Plan which included certain Protective Action Guides (PAGs).
Other official bodies, such as the Federal Environmental Protection Agency and the Food and Drug
Administration have also adopted the PAG approach. The various PAG systems are not identical,
but they do provide sufficiently consistent guidance
to avoid confusion when attempting to apply them.
These PAGs are recommendations keyed to thedoses of radiation that a population is anticipated toreceive after an accident if the population takes noprotective actions. For example, the PAG systemrecommends considering a take-shelter advisory ororder when the expected dose to a member of thegeneral population exceeds 1000 millirem. (A millirem is one thousandth of a rem, a unit used to express the amount of radiation dose). While the
PAGs are meant to serve as planning guides, the intent is that the State should require that some protective action be taken when anticipated doses approach the PAGs.
The Plan for Nuclear Power Generating Station
I ncidents, issued by the Pennsylvania Bureau of Radiation Protection in 1977 significantly expanded thePEMA plan's treatment of PAGs.
Applying these protective action guides requiresconsiderable judgment. Although each protective
action option can effectively reduce a population's
radiation exposure, each also imposes certain
costs. For example, while evacuation of an area
where significant levels of radiation are going to occur would reduce the population's exposure to radiation, such an evacuation would impose the serious
financial cost of moving and caring for evacuees, interrupting business and employment, disrupting social and educational activities, and causing healthrisks from traffic accidents and moving critically ill
persons from hospitals. Thus, before deciding toorder an evacuation, the State must weigh and balance the likelihood of occurrence of significant radiation levels, the likely reduction in exposures, and101 0

the costs of evacuation against the effectiveness ofother protective measures such as sheltering.
As suggested above, a decision to take a protective action depends in part on existing and anticipated radiation levels. If forecasting radiation levels isimpeded by uncertainty about further releases of radioactivity from the reactor, one approach is to assume the worst and simply to proceed with the appropriate protective actions. However, the framework of the PAGs is built around the concept thatthe exposures are likely to occur unless protective
actions are taken. In the emergency response to
TMI, the likely releases were very low compared to
the PAGs. However, there was a small chance ofvery large releases which, if they occurred, would
result in exposures that would far exceed the evacuation PAGs. This uncertainty about predicting
further releases from the reactor contributed mightil y to many individuals' opinions about the need totake protective actions at particular points in time.
b. Consideration of Sheltering and Evacuation
The first serious consideration of ordering anevacuation occurred early Wednesday morning, 3hours and 45 minutes into the accident. An evacuation alert was sounded when, based on radiological32
calculations supplied by Met Ed through BRP,
PEMA advised York County Civil Defense to beprepared to evacuate the area of Goldsboro andBrunner Island, 33 west of TMI. Governor Thornburgh was immediately informed of this alert. Thirty
minutes later, at 8:15 a.m., the evacuation alert wascalled off by PEMA34 when BRP advised PEMA thatthe results of onsite and offsite radiation monitoring
did not confirm the calculations; 35 i.e., there had
been no major radiological releases.
As events proceeded over the next 24 hours,
Pennsylvania's Lt. Governor Scranton, head of thePennsylvania Emergency Management Council,
carefully followed the course of the accident andprovided State leadership. During this time the situation at the reactor appeared to be stable andperhaps improving. But as radioactive releases
continued, it became clearer that there had been
substantial core damage, and there obviously were
obstacles to achieving a cold shutdown. Therefore,
concern about the actual status of the plant began
to build.
During a phone conversation on Thursday morni ng, Lt. Governor Scranton asked NRC Commissioner Victor Gilinsky whether school children in theGoldsboro area should stay indoors. Gilinsky did
not reply, but in a return call to Mark Knouse, aScranton staff member, Harold Denton, NRC, advised that it was not necessary for children to stayi ndoors. When asked about sick and elderly persons, Denton also said he didn't think sheltering
was necessary. He based his position on the factthat the radiation readings at TMI were well below
EPA protective action guidelines. This was thefirst time since the Wednesday morning evacuation
alert that the question of precautionary protective
measures was raised by people in the Governor's
office with people outside the State offices.
Early Thursday afternoon Pennsylvania Secretaryof Health Dr. Gordon MacLeod placed a conference
call to Dr. Niel Wald, Chairman of the Department ofRadiation Health in the University of Pittsburgh's
Graduate School of Public Health. MacLeod sought
to reinforce the State's knowledge of radiation
health. The call was placed from the Governor's office in Harrisburg, where the Governor, the Lt.
Governor, and members of their staffs were gathered, and concerned the effects of radiation exposure, particularly at high levels. There was no mention of evacuation. 37
Later Thursday MacLeod discussed the evacuation of pregnant women and young children with
BRP's Gerusky, PEMA's Henderson, a representative from the Lt. Governor's office, and Mr. Welch,
the Deputy Secretary of Health. 38 The consensus
of the group was that such action was not warranted.
Later that afternoon MacLeod received a phone
call from Dr. Anthony Robbins, the Director of the
National Institute of Occupational Safety and Health(NIOSH) of HEW in Washington. MacLeod reported
l ater that Robbins expressed serious concern about
the accident because of "the inability ... to shutdown the reactors [sic]," and recommended that theState "consider evacuation of the population surrounding Three Mile Island." 39 According to MacLeod, Robbins added that he was making his
recommendation after consultation with the Bureauof Radiological Health of the Federal Food and Drug
Administration. Robbins has said that the phone call
was an "informal contact" and denied he made any
recommendations about evacuation. 40
Following this phone conversation, MacLeod
placed a conference call to PEMA Director Henderson, Gerusky, Governor's aide John Pierce, and
Deputy Health Secretary Welch, to transmit Robbins' concern and recommendation. Again, thegroup felt that radiation levels were "not sufficiently
high to warrant evacuation" and that there was not
sufficient information about the ability to shut down
the reactor to make a decision about evacuation. It
was agreed when the plant moved into "an experi101 1

mental mode ... with respect to the shutdown process," that they "would be back in touch withrespect to possibility of evacuation." Also during
the same conference call, MacLeod focused attention on the greater sensitivity of the fetus andyounger children. Again the group by poll unanimously took the position that there was no reason
at that time to evacuate pregnant women and chil41
dren under the age of 2.
MacLeod later heard about the plant's dischargeof contaminated wastewater and interpreted the action to be a result of human error. This, combinedwith his evaluation that events on Wednesday werecaused by similar technical errors, led him to believe
the situation at the plant was unstable. On Friday
morning he instructed his deputy to attend all meeti ngs with the Governor that day and to recommend
strongly that the Governor consider advising pregnant women and children under the age of 2 to42This was the situation in theleave the area.
Governor's office on Friday morning.
Early Friday morning, events at the plant resulted
in the release of radioactive materials to the atmosphere. Floyd, the Supervisor of Operations at
TMI-2, independently decided that he personallywould alert PEMA to the possibility of a need "to43
He wasevacuate people downwind of the plant."
not able to get through to PEMA, but he did reachthe Dauphin County Civil Defense Office and asked
that they have someone from PEMA call him. Before Dauphin County could relay the message, Floyd
called PEMA at 8:40 a.m. and spoke to Carl Kuehn.
Floyd told Kuehn that the plant had an "uncontrolled
release," that the plant might evacuate noncriticalpersonnel, and that PEMA should be prepared toevacuate people downwind. Floyd then asked
44
Kuehn to tell BRP that he, Floyd, "may need help."
At the same time, the plant Emergency Control Station was on another line telling PEMA's Jim Cassidy
about the 1200-mR/h reading taken 600 feet above
the plant and the 14m-R/h reading at the site boundary, but not mentioning the possibility of evacuation on site or off. 45 Earlier, the plant Emergency
Control Station had reported to BRP about the"planned but uncontrolled release," and had statedthat "the first release would have been the highest
amount of radiation and that levels should decreasesignificantly over the next few hours back down towhere they were the day before." 46 PEMA's Lamison called BRP's Reilly at Floyd's request, and Reilly
said she had received similar information from theplant and would send radiological monitors to thearea.
Lamison then reported both Cassidy's andKuehn's information to PEMA Director Oran

Henderson, noting as well Kuehn's description that47
Henderson immediFloyd was extremely excited .
ately so informed the Lt. Governor, who reported
the 1200-mR/h reading to the Governor's office.
Paul Critchlow, the Governor's press secretary,
walked to the next office where the NRC's Region I
press officer, Karl Abraham, was located, to seek
verification of the report. Abraham said he would
check with the NRC Headquarters.

At about 9:15 a.m. Collins, at the NRC Headquarters, called Henderson and asked whether PEMA
had heard about the releases. He was told PEMA
had received a report of 1200 mR/h. PEMA's information would of course have been similar to the
NRC's, since it had come full circle from Floyd to
PEMA to Critchlow to Abraham to the NRC's Emergency Management Team to Collins and back to
PEMA's Henderson. Collins asked if Henderson had
issued any evacuation orders and was told PEMA
was awaiting word from the plant. Collins thenrecommended that PEMA go ahead and evacuate
people out to 10 miles from the plant in the directionof the plume. Henderson responded that PEMA
would consider ordering a 5-mile evacuation all
around the plant because there were no plans for a
10-mile evacuation and the wind direction was too
unstable to predict the plume's path. On receiving
NRC's recommendation to evacuate, Henderson im48
mediately notified the Lt. Governor.
Thus, within 15 minutes, senior NRC officials in
Bethesda had made and communicated an evacuation decision to the State, beginning a chain of
events that significantly heightened the anxiety ofthe people living around TMI. Like the first evacuation alert on Wednesday morning, Friday's event
began with a projection of possible radiation expothe
population.
However,
unlikesuretoWednesday's alert, the NRC's Emergency Management Team decided on an evacuation without verifying the reported plant status and offsite radiation
readings; nor had PEMA's Henderson received suchan evaluation from BRP.
Henderson's deputy, Craig Williamson, informed
Gerusky of Collins' call and of the NRC's urgent
recommendation. Gerusky responded that BRP had
no information to justify an evacuation but would
check and get back to PEMA. Gerusky also questioned why Collins had made his recommendation to
PEMA instead of BRP. The answer was that Collins
had worked with BRP for a long time and that heknew "what we [BRP] were supposed to do, and[knew] that we had the responsibility for making therecommendation." 49

As the Lt. Governor was briefing the Governor,
Henderson told the Dauphin County Director of the

Office of Emergency Preparedness, Kevin Molloy, tobe prepared for a possible evacuation and to expect
an order in 5 minutes, because Henderson was 90%
sure of such an order from the Governor.
Following Dauphin County's emergency plans,
Molloy made all the appropriate notifications within
the county and then went on WHP radio, the primary emergency broadcast station in the vicinity, toadvise that, as stated later, "there was a possibility
we might have to evacuate, and if we did, that this iswhat the people should take with them, and basical50
l y this is where they should go."Meanwhile, BRP had been trying to check thebasis for Collins' recommendation. BRP nuclear engineer William Dornsife spoke to NRC InvestigatorCharles Gallina at TMI. Gallina could not believe theevacuation recommendation since he saw no reason for it. BRP's Margaret Reilly made it quite clear
to Collins that BRP also saw no reason to order an
evacuation and cited Dornsife's conversation with
Gallina. Collins said he was following orders andthat NRC Chairman Hendrie would soon call theGovernor. At 9:45 a.m. Governor Thornburgh called
Henderson, asked about Collins, and was told that
Collins was not known personally to Henderson, butthat Collins enjoyed a good reputation among BRP
staff and was considered reliable. BRP personnel
completed data checks with the NRC staff in
Bethesda and on site and were convinced that evacuation was not necessary. BRP was not able to
make phone connections with the Governor's officeor with PEMA, however. The phone system wasoverloaded with reaction to Molloy's broadcast
alerting the population to the possibility of evacuation. Dornsife rushed to the PEMA office and Gerusky to the Governor's office to present personally51
their opposition to evacuation.
At about 10:00 a.m. a siren was sounded in Harrisburg. Apparently it was not the county civil defense siren; it was perhaps located on State property. Other sirens went off twice in the city of52Harrisburg, further increasing tensions in the area.
At 9:59 a.m. Thornburgh called Hendrie, who advised after a brief exchange that "it would be desirable to suggest that people out in the northeast
quadrant within 5 miles of the plant stay indoors forthe next half hour." Their conversation was interrupted to allow Hendrie to receive informationtransmitted from the site to the NRC's Incident
Response Center in Bethesda. When they resumed
their conversation, Gerusky had arrived in the
Governor's office with current radiation readings.
The men compared these numbers, and while
NRC's readings were higher than BRP's, they wereboth substantially lower than the 1200 mR/h that
had been registered earlier.

101 2

Hendrie repeated that it would be prudent tohave people within a 5-mile radius stay indoors thatmorning until "our information improves, hopefully it
will, then we can see where we go from there."
Gerusky said the wind was picking up and theplume should dissipate, thus, as he stated later, "itprobably didn't make any difference now whether
Hendrie felt
people stayed indoors or not."Gerusky's comment was not a bad judgment, but
explained that the NRC's suggestion about people
staying indoors was more of a "precautionary one,from a feeling that the material is there." Thornburgh then asked if there could be any more ofthese releases and was told "we may very well getthem again, I think." Hendrie added that he hoped
the NRC would know from the plant "in advance" ofsuch a situation and would be "ready to anticipate
what we may need to do." Thornburgh asked
whether he should order a precautionary evacuationi n anticipation of more releases. Hendrie said: "Itwould be just as well to wait until we know that they
are going to have to make some kind of a watertransfer ... and then at that time, go ahead andmake a precautionary evacuation." In this fashion,
Hendrie in effect countermanded Collins' and the
NRC's Emergency Management
Team's recommen53
dation for evacuation.
After he talked with Hendrie, the Governor, at
10:25 a.m., made a live broadcast on WHP radio toattempt to deal with the many evacuation rumors.
At the same time, Critchlow briefed newsmen about
the Governor's talk with Hendrie, the 1200-mR/hreading over the plant and that 25 mR/h was thehighest reading recorded off site, and that there wasno need for evacuation. However, he advised people within a 10-mile radius of the plant to stay indoors. 55 Instead of the 36 000 people within the
5-mile radius suggested by Hendrie, the 10-mile radius encompassed 135 000 persons. (Critchlow
said it had been his mistake, and that he had
misheard Hendrie.) This broadcast advising people
to stay inside, close the doors and windows, andshut down air conditioners followed by only 1 hour
Molloy's WHP broadcast directing people within 5
miles of TMI to pack their bags and be prepared toevacuate. The Governor did not end
56,57 his takeshelter advisory until midnight Friday,
although
PEMA mistakenly notified the affected counties atnoon that it had been lifted. 58
President Carter called Hendrie at 10:45 a.m. Friday for a plant status update. During this call it was
decided to send Harold Denton to the site to serveas the President's direct contact and responsible
senior official regarding plant matters. Following histalk with Hendrie at 11:15 a.m., President Carter
called Governor Thornburgh. The President said hewould be sending Harold Denton to be thePresident's representative on site, that Jessica
Tuchman Mathews would be the State's contact
point in the White House, and that the President
would provide communications systems to link thesite with the Governor's office, the NRC, and theWhite House. Thornburgh later described his talkwith the President in his 12:30 p.m. press conference:

Based upon the evidence and best technical advice
available, the President concurred with me that
there continues, at present readings, no reason forpanic or implementation of emergency measures.. .
The President has dispatched ... Harold Denton ...
to assist me and work with our experts, on thescene, to monitor the situation and keep me, andthrough me the public, fully advised.

I n response to a newsman's question, Thornburgh elaborated that the President was concernedthat there be no panic and that "there be appropriate communication59of the best estimate of the situation to the people."
At 11:40 a.m. Hendrie called the Governor. Hendrie began the conversation with a description of
the plant's technical status and noted the possibilityof further releases. The Governor mentioned his
Secretary of Health's concern about the special
sensitivity of pregnant women and young children,
soliciting Hendrie's comment about the proposed
evacuation. According to Thornburgh, Hendrie"agreed at that time that this would be a prudent
step to take as a precautionary move." 60 They discussed what evacuation zone the advisory should
define-1, 2, or 3 miles. Gerusky, in the room with
the Governor, volunteered "5 miles," since the State
had evacuation plans for 5 miles, and the matter
was settled. Upon the conclusion of the phone
conversation, State officials discussed how best toi mplement the "young children" advisory; theyagreed to draw the line at preschool-age children.
PEMA's Deputy Director Craig Williamson had arrived in the Governor's office earlier and was able toi dentify possible mass care centers and describe
the school situation. It was appreciated that mothers with both preschool-age and school-age children would want to take the latter along, and it wastherefore decided to close schools as well. At his
12:30 p.m. press conference Governor Thornburgh
announced: bl

Based on advice of the Chairman of NRC and in thei nterests of taking every precaution, I am advisingthose who may be particularly susceptible to theeffects of radiation, that is, pregnant women andpreschool-age children, to leave the area within a
5-mile radius of the Three Mile Island facility until
further notice. We have also ordered the closing of
any schools within this area. I repeat that this and101 3

other contingency measures are based on my beliefs that an excess of caution is best. Current
readings are no higher than they were yesterday.
However, the continued presence of radioactivity inthe area and the possibility of further emissions
lead me to exercise the utmost caution.

This was the only evacuation ordered as a resultof the accident at TMI, and it was merely a precautionary advisory. However, the question of evacuation was still seriously considered for the next
several days. The existence of a hydrogen bubble
had been determined on Thursday night, and concerns regarding core cooling and an explosion of
the hydrogen bubble continued through Sunday.

Friday afternoon, Jay Waldman, the Governor's
Executive Assistant, and Paul Critchlow, also in the
Governor's office, established phone contact with
Watson, Mathews, and Eidenberg in the WhiteHouse. Sometime after 1:00 p.m. Mathews briefed
Waldman on the hydrogen situation. The briefing
was based on the information she had received earlier from Gilinsky and on Hendrie's briefing in the
Situation Room. 62 The foreboding news was passed
on to the Governor, who interrupted the phone callto obtain a direct briefing from Mathews. The
Governor explained to Mathews his problem with
two information sources in the NRC, one at the site,another in Washington; he was getting inconsistent
information. He desperately needed a reliable central source. Denton, who had arrived at the site but
was not yet in direct contact with the Governor,
would now assume that role. When Hendrie called
the Governor at 3:41 p.m., Thornburgh already had apretty good idea about the bubble problem. Hendrie
described the situation and said Met Ed, Babcock &Wilcox, and the NRC then agreed that core damagewas "considerably more extensive than we hadthought yesterday." He added that the situation
was fairly stable at the moment, should continuethat way for several days, and, meanwhile, Met Ed
and the NRC were "working hard figuring how tocome down out of this situation." In response to aquestion, Hendrie said it might be prudent to evacuate out to 20 miles "if we suspected getting a fairly
husky release." When asked, "What are the potentials for an explosion that would rupture the core?
Rupture the vessel?" Hendrie replied, "There isn't
any oxygen in there to combine with that hydrogen,so the63answer as far as I know is pretty close to
zero."
The first bubble scare-that the bubble would
cause a core meltdown-was born as UPI passed
on a story stating that the TMI accident posed theultimate risk of meltdown. This shattered the calmin the Harrisburg area: the Governor had 4 hours
earlier reported to the people that, based on his
101 4talks with President Carter and NRC Chairman Hendrie, "There continues [to be] no need for panic or
i mplementation of emergency measures." 64 To try
to put the UPI story in perspective, the NRC Commissioners in Washington struggled to compose apress release downplaying the presence of a large
condensible bubble in the top of the vessel which
could present the possibility of interrupting coolant
flow. At his press conference at 5:00 p.m., Jody
65
Powell indicated that meltdown was speculative.
Later that night, at 10:00 p.m., Governor Thornburgh,
Lt. Governor Scranton, and Harold Denton held apress conference. In a further effort to calm thesituation, the Governor reported that he had justspent an hour and a half with Denton, whom hedescribed as being assigned by the President to
Pennsylvania "for the duration." Thornburgh went
on to announce their belief that "no evacuation
order was necessary at the time." At the press
conference, Denton put the meltdown story to rest66
by saying its possibility "was very remote.„
The notion of a bubble explosion again became apublic concern when, at his Saturday afternoon
press conference, Hendrie was asked about the
chances of an explosion. He responded:
Okay the bubble, with regard to the bubble in thevessel, there is ... that is a problem which is ofcourse and which we are working on very intensively at the moment. As long as the bubble hashydrogen, steam, fission product gas composition,
why it's not flammable. But if enough oxygen overa longer period of time were evolved, why it could
become a flammable mixture. Now, it's a fairly highpressure 1000 pound per square inch and contained in the vessel dome; in fact at the moment alittle too well contained for our purpose; so that
there aren't ignition sources at hand, and the indicators out of staff calculations and other calculations are being done for us by other experts aroundthe country. This preliminary indication from that isthat we are some time from any possibility of a
flammable condition. But that is a preliminary
result, and it is a concern, and we are working very
hard on that 87

Earlier that day Hendrie had called Denton at thesite to ask him to be sure the Governor had a senseof the risk that oxygen presented and its implications for an evacuation decision. Denton talked to
the Governor by phone to explain the estimatedli kelihood of flammability and explosiveness.
Following his press conference, Hendrie called
the Governor to say, "We've had some returns fromthe technical groups around the country that are
working on the problem, and it appears that it's atleast not near term, not something that we have todeal with here immediately." 68
Later that evening Stan Benjamin, an AP reporter,
following up on Hendrie's statements about the oxy-

gen problem, prepared a story and confirmed it with
NRC Assistant Press Officer Frank Ingram and with
Edson Case. Around 8:30 p.m. Benjamin filed an
editorial advisory: "Urgent (with Nuclear) The NRC
now says gas bubble atop the nuclear reactor atThree Mile Island shows signs of becoming potentially explosive. A story upcoming." 69 The Governor received a copy of the wire story advisory. He
asked Critchlow to call Denton, who said the danger
was hypothetical. Denton was asked to stop by thecapitol newsroom on his way over to the Governor's
office to put the story to rest. Denton told thenewsmen that the bubble would not be explosive forfrom 9 to 12 days, there was plenty of time tocorrect the problem, and there was no danger atthat time. Denton then proceeded to meet with theGovernor and his staff. They held a joint press
conference at 11:00 p.m. at which the Governor
again tried to reassure the people with the following
opening remarks:

Good evening. I have just completed a routine
briefing from Mr. Denton. These briefings havebeen held by phone since his arrival here and hehas joined us last night and this evening for a detailed review of the day's events.
There have been a number of erroneous or distorted reports during the day about occurrences or
possible difficulties at the facility on Three Mile Isl and and this briefing this evening was of particularsignificance in that respect.
Mr. Denton in our discussion assured me andwill be available to answer your questions that there
is no imminent catastrophic event foreseeable atthe Three Mile Island facility and I appeal to those
who may have reacted or overreacted to reports tothe contrary today, to listen carefully to his characterization of the current status of the situation. I
appeal to all Pennsylvanians to display an appropriate degree of calm and resolve and patience indealing with this situation.

Thornburgh added that President Carter would
be coming to the area to make a personal onsite
visit and urged that this was "an important vote ofconfidence in the kind of work that is proceeding
there and a further refutation in the kind of alarmist
reaction that has set in in some quarters." 70
The news stories about possible massive evacuation and the bubble possibly exploding had taken
their toll. County officials were receiving numerous
requests for information, but all the county had were
two PEMA teletype messages reporting no change
i n plant conditions. Not only were they unable torespond intelligently to the concerned public, butthey felt they were unable to anticipate what they
were expected to do. State Senator Gekas, who
happened to be in the Dauphin County emergency
operations center at the time, witnessed this frustration. When he learned that Dauphin County was un-

101 5able to reach the Governor to request more information, the Senator himself tried to make contact, to
no avail. He finally told the Lt. Governor's office that
if they did not get in touch with Dauphin County witha little more information, Dauphin County would be
performing its own evacuation at 9:00 a.m. the nextmorning. 71
Early Sunday morning Lt. Governor Scranton and
Dr. Robert Wilburn met with Senator Gekas andDauphin County civil defense officials to attempt toaddress the serious county-level concerns. In these
discussions Scranton assured the county officialsthat he would try to correct the situation. Molloy
said the Lt. Governor was "surprised, extremely, I
think. I don't think that he was fully aware of someof the problems
that we were facing at our particular
72
level...."At noon Governor Thornburgh left Harrisburg tomeet President Carter, who arrived in Middletown at
1:00 p.m. After his briefing from Denton, thePresident toured the TMI plant, including the Unit 2
control room, accompanied by Thornburgh and
Denton. At 2:00 p.m. the President made a statement to the people of Middletown, Pennsylvania, 3miles from the plant. He explained that the reactor
was stable, but that certain actions might have to betaken to bring the reactor to cold shutdown. In thatevent the Governor, he said, might ask the people in
the area to take certain precautionary action. The
President continued by asking the people to carryout the Governor's instructions "calmly and exactly "73

By late Sunday night it was clear that the bubble
no longer posed a substantial problem from a corecooling standpoint and that there never had been achance it might explode. While precautionary planning for evacuation continued, the spectre of evacuation no longer loomed large.
I n retrospect, the levels of radiation and radioactivity measured in the environment around TMI did
not require protective actions by any establishedstandard. The maximum radiation dose estimatedto have been received by any one member of thegeneral population was less than 100 millirem; theaverage dose to an individual in the population
within a 50-mile radius of the plant was 1.4 millirem.
For comparison, the natural background radiation in
Pennsylvania is about 100 millirem per year for eachi ndividual. The collective dose to the total population within a 50-mile radius of the plant has been
estimated to be in the range of 1600 to 3300
person-rem. (A person-rem is a unit used to express the cumulative radiation dose per 1000 people; e.g., 1000 000 people exposed to an average of
2 millirem each would result in a total exposure of2000 person-rem). The number of excess fatal

cancers projected to occur because of this doseover the remaining lifetime of the population within
50 miles of TMI is less than one, and had the accident not occurred, the number of fatal cancers
that would be normally expected in this size population over its remaining lifetime is estimated to be
325 000. The projected total number of excess
health effects, including all cases of cancer (fatal
and nonfatal) and genetic74ill health to all future generations, is less than two.

This analysis does not support the conclusionthat evacuation advisories should not have been
made, however. It demonstrates that these advisories were issued because of uncertainty about
the status of the plant and not because of actual orli kely radioactive releases which would result in exposures that would approach the established PAGs.
This points up the need for better and more prompt
i nformation regarding plant status in an emergency
situation in order to avoid as much of this uncertainty as possible. For, while uncertainty about the
chance of a postulated release may justifiably provide the basis for a decision to evacuate, a 5%chance should weigh lighter in the balance than a
30% chance.
c. Aftermath of the Advisories
Based on an extensive survey taken by an NRC
contractor after the accident, 75 approximately
144 000 of the 370 000 people living within 15 milesof TMI evacuated the area between Wednesday and
Sunday. Details of this evacuation and of the resultant socioeconomic impacts are provided in Section
IV of this volume and are summarized below.

1. Approximately 39% of the people living within 15
miles of TMI evacuated. This ranged from about
60% of the people living within 5 miles to about
32% of those living 10 to 15 miles away.
2. Approximately 14% of the total number who evacuated did so before Friday. More than 50%
evacuated on Friday.
3. Of those households within 15 miles of TMI that
had evacuees, about 36% had a pregnant woman
or a young child; fewer than 5% had a pregnant
woman or a young child and also resided within 5
miles of TMI.
4. Approximately 65% of the pregnant women andyoung children living within 15 miles of TMI evacuated. This ranged from about 93% of those living within 5 miles, to about 57% of those living 10
to 15 miles away.
5. The median length of time evacuees remainedout of the area was 5 days.

6. Most evacuees stayed with friends or relatives.
7. Evacuees traveled an average distance of 100
miles.
I mmediately following the 12:30 p.m. advisory by
the Governor on Friday, two mass care centerswere established for the evacuees: York County
opened one in its Central High School in York,Pa., 76 and Dauphin County operated the second in
the Hershey Arena in Hershey, Pa. 77 Though
operation of these mass care centers was a county
responsibility, the American Red Cross provided
substantial assistance to the counties by providing
personnel and supplies. 78
On Saturday morning, when the evacuation scare
was almost at its peak, the total number of evacuees at the two shelters was only about 185. 79 On
Sunday, April 1, the York County Center was closed
because few evacuees had come to this shelter andall evacuees went to the homes of friends or relatives. 80 During the next several days the number ofpeople at the Dauphin County Center dropped as
people either returned to the evacuated area, went
to stay with friends or relatives, or used advance insurance payments from the utility's insurance
underwriters to move into motels. 81 The Governor
did not officially lift the evacuation advisory until
3:00 p.m. on April 9; 82 however, on April 7, 1979,
the Dauphin County Center was closed and the 17
remaining displaced persons were moved to
motels. 83
d. Lifting the Evacuation Advisory
The evacuation advisory for pregnant women andyoung children and the school closings remained in
effect from Friday, March 30, until Monday, April 9.
During this entire period, the situation at the plantremained stable, but radiation releases continued at
a very low level, and the plant never achieved a cold
shutdown.
Therefore, Governor Thornburgh could point tono single, major event as demonstrating to the public such an improvement as would justify bringing
people back into the evacuated area.

The basic problem was that on March 30 there
was no clear and demonstrable physical fact thatserved as a basis for issuing the advisory: the basis
was one of uncertainty as to the future status of thereactor, since unlikely but possible future events at
the reactor could release large quantities of radioactivity that would greatly exceed the population
exposures specified in the PAGs. There was muchconcern about the plant status on Friday, but by all
estimates there was no immediate hazard. While101 6

radioactivity was released on Friday, it was not continuous, and the maximum exposures measured offsite were almost a factor of 100 below the protective action guidelines. We will never know the precise influence that the following events had on thecollegial decision (between the Governor's Officeand the NRC) to evacuate.

1. The emergency call between Floyd of Met Ed
and Kuehn of PEMA during which Floyd allegedly
recommended evacuation in an excited voice.
2. The NRC's recommendation through Collins to
PEMA to evacuate downwind for 10 miles.
3. Henderson's advisory to Dauphin County to get
ready for an evacuation "in 5 minutes" and his
recommendation to the Governor to evacuate out
to 5 miles (both done without BRP concurrence).
4. Dauphin County's subsequent public announcement over the radio for the citizens to get readyfor an evacuation announcement.
5. The sounding of civil defense sirens.
6. The 10:25 a.m. advisory by the Governor for people within a 10-mile radius to stay indoors.
7. The flood of telephone calls from the public, sufficient to jam the telephone exchanges.

The NRC and the Governor's office pondered forseveral days over the criteria for lifting the advisory.
Finally, on Monday, April 9, Governor Thornburgh
li fted the advisory. Denton stated that he recommended this action to Thornburgh because (1) thecore was much cooler and all hydrogen gas had
been removed; (2) the containment was at negative
pressure; (3) offsite exposures were very low; (4)iodine releases were under control; and (5) there
had been no liquid releases in excess of thosethat84
would be permitted during normal operations.
e. Findings and Recommendations

The preceding narrative describes the eventsl eading to the decisions regarding the take-shelter
and evacuation advisories issued by the Governor
and the results of these advisories. We draw anumber of findings from the preceding description.
Some of these findings lead to the recommendations presented in this section; others lend support
to recommendations made in other sections. The
findings of this section are:

1. Uncertainty of information regarding plant status
and the potential for large releases of radioactivity were the principal causes of the concerns andfears of Government officials and the public andfor the decisions to advise taking shelter within a
10-mile radius and to advise that pregnant wom101 7

en and preschool-age children evacuate fromwithin a 5-mile radius. This uncertainty arosefrom lack of information, the existence of incorrect and conflicting information, poor or inaccurate communication of information, and improper assessment or evaluation of information.
2. Radiation exposures projected on the basis ofmeasured or likely releases were a factor of 10 to
50 lower than any protective action guidelines fortaking shelter or evacuating.
3. The Governor of Pennsylvania acted responsibly
i n his actions to verify the recommendation toevacuate made by Harold Collins of NRC; however, in a fast-moving accident with serious offsite
consequences, taking the time required for suchverification might have serious public health andsafety consequences. The TMI accident was nota fast-moving accident and, had it been, we believe it highly probable that the verification process would also have been more rapid (e.g.,
Gerusky would likely have recommended evacuation also, under such a postulated situation,
since he was aware of the plant status).
4. The TMI accident and the ensuing advisory for apartial evacuation resulted in about 144,000
evacuees, at least 20 times more than thenumber of pregnant women and young children(and their families) living within 5 miles of TMI.
5. Whereas the Governor testified that the liability
for, and economic impacts of, an evacuation
never entered
his mind when deciding whether to85
andwhile no evidence was
evacuate,
uncovered to the contrary, such considerations
could be of importance to a future decisionmaker.
This question of economic disincentives to evacuation in its broadest context (i.e., economic
impacts on citizenry as well as on the State andFederal Governments) has not been well thoughtout or studied. For example, officials in thePennsylvania Department of Agriculture told usthat there is a need to eliminate economic disincentives for farmers to evacuate. They notedthat a farmer would be reluctant to evacuate andleave his livestock unless it was clear to him that
he would not be financially destroyed if his live.tock died while he was away. They suggested
that if farmers knew they would be financiallyindemnified against such losses, they would be
more inclined to comply with an evacuation order.
6. Protective actions cannot be effectively recommended from Washington unless substantially improved communications are provided and information is verified by onsite personnel. However,
we believe it preferable that such recommendations not be made by persons far removed fromthe accident.

7. The decisionmakers suffered from a lack ofunderstanding of the protective action guides andthe usefulness of various protective actions.

the EPA-NRC proposal for 10-mile evacuation planning and the NRC estimates during
TMI of up to a 10-mile evacuation for possible TMI scenarios suggest that the formalplanning should extend to that distance;planners must recognize, however, that
substantial voluntary evacuation will extend
to much larger distances.
d. The adverse health, safety, social, andeconomic impacts of various protective actions.
5. FEMA must study and, to the extent reasonable,
l ower possible economic barriers to protective
actions such as evacuation. Although one cannot
reduce the overall costs of an evacuation, one
can determine whether the participants in theevacuation decision and in the evacuation itself
should be made more immune to the economic
consequences; i.e., should these costs be borneby a larger segment of society through insurance
or the use of Federal or State revenues. FEMA
must resolve the following questions.
a. Who bears liability for private loss resulting
from evacuation? Are Government officials
personally liable for loss resulting from suchdecisions? Is any indemnity available?
b. Who bears the risk if a loss is incurred as aresult of either an ordered or "advised" protective action, and the radiological threat
does not materialize?
c. Will a farmer or a businessman with perishable stock or capital investment evacuate
as ordered or advised?

Based on the above, the detailed recommendations of this section are:

1. Official channels for the transmittal of protective
action recommendations to the responsible decision authority must be set up in advance and understood by all parties. All participants in thisprocess should be predesignated to the extent
possible.
2. Procedures must be established in advance by
the decision authority for verifying protective action recommendations and their bases. These
procedures must provide for timely verification,according to the temporal nature of the publichazard.
3. The NRC, in cooperation with HEW and EPA,
must develop clear and commonly acceptable
protective action guidelines (PAGs) that are understood by decisionmakers and can be appliedi n a relatively unambiguous manner. Consistency
between 10 C.F.R Part 140, and EPA and FDA
protective action guidelines should be achieved.
Projected dose calculations associated with
PAGs should be based on the following:a. Forecasts of likely radiological releases, including reasonable assumptions regarding
present and future plant status.
b. Likely meteorological conditions.
c. Existing demographic and topographic
characteristics.
4. The NRC, in cooperation with EPA, HEW, andFEMA, must evaluate the array of protective actions available in the event that PAGs may be exceeded and develop recommendations for action
accordingly. These recommendations must be
based upon consideration of the following:a. The effectiveness of various protective actions (e.g., precautionary evacuation, partial
evacuation, sheltering, use of thyroid blocking agents, food interdiction). Particular attention should be given to sheltering andthe conditions under which it should berecommended; e.g., the increased shielding
effectiveness against low-energy radiations,such as from xenon, must be considered in
evaluating the sheltering alternative.
b. The time required to implement various protective actions compared to the likely
ti mespan of the emergency.
c. The area surrounding the nuclear facility,
within which specific effective actions must
be appropriately planned. In this regard,

5. EVACUATION PLANNING BEFORE
AND DURING THE ACCIDENT
a. Introduction
In July 1977 the predecessor to the Pennsylvania
Emergency Management Agency (PEMA) added Annex E, entitled "Nuclear Incidents (Fixed Facility)" tothe Commonwealth Disaster Operations Plan. 86
Annex E generally describes State, county, and local responsibilities during a nuclear emergency andassigned primary responsibility for responding to anuclear emergency to county and local governments. The PEMA plan had never been formallygiven to the NRC for concurrence.
I n 1978, at PEMA's suggestion, the three counties
within a 5-mile radius of Three Mile Island (Dauphin,
Lancaster, and York) developed emergency plans
for accidents at TMI, including 5-mile evacuation

1 01 8

plans. Each of the three county plans differed
greatly in detail, although each described individuals
or organizations responsible for carrying out specifi c portions of an evacuation, described official communications channels, identified the location of masscare facilities, and made provisions for informing the
public. None of the localities within 5 miles of theplant had such emergency plans.
PEMA established a planning zone of 5 miles
around TMI and all other powerplants in Pennsylvania to standardize planning within the State. The
distance of 5 miles was selected because the largest Low Population Zone (LPZ) specified by the
NRC for any nuclear powerplant in the State wasabout 5 miles. The LPZ for TMI was about 2 miles.
At the time of the accident, PEMA believed the 5mile planning zone was adequate and saw no needfor more extensive planning. During the first 2 daysof the accident, PEMA reviewed the 3 counties' emergency plans, which were on file in PEMA's offices.
The county emergency management directors of
the three affected counties were also reviewing theiremergency plans and their county resource inventories, which list all the personnel and equipment
resources available within the counties. By Thursday evening PEMA officials and the county directors
believed the situation at TMI had significantly improved, the emergency would soon be over, andtheir plans would not be called into service. 87
This situation changed on Friday, March 30, foll owing the NRC's recommendation to Oran Henderson, the Director of PEMA, to carry out a 10-mileevacuation downwind of the plant. The extent of
the NRC recommended evacuation made Henderson doubt the adequacy of the existing 5-mile plansand prompted his decision on Friday morning to expand the emergency planning zone to 10 miles.
Later the same day, while briefing Governor Thornburgh on plant status, Harold Denton stated that
20-mile evacuation planning would be prudent. Early Saturday morning, Henderson called the emergency management directors of the 6 counties
within 20 miles of TMI and instructed them to begin
planning for the evacuation of all residents within 20
miles of TMI.
b. State, County, and Local Planning
Expanding the planning zone from 5 to 10 andfrom 10 to 20 miles significantly complicated evacuation planning and affected the ability of the counties to carry out an evacuation without outside assistance. The 5-mile zone previously planned fori ncluded about 38000 people, only a few nursing

homes that required special handling and transportation for their residents, and no hospitals or prisons. In addition, evacuees from each of the threeaffected counties could have been sheltered within
their own county; that is, no outside counties would
have been required to provide mass care centers.
As the planning zone increased to 10 miles, it encompassed portions of Cumberland County, and theaffected population increased to about 165000.
The 10-mile zone included several additional nursing
homes and three hospitals.
The 20-mile zone covered portions of two morecounties (Lebanon and Perry) and more than
600000 people, 13 hospitals, a major prison, and al arge number of nursing homes. To handle theoverflow of evacuees, 21 host counties would havebeen required to provide mass care shelters.
By Saturday morning, March 31, the emergency
management officials in each of the six counties
within 20 miles of TMI had begun planning for a
20-mile evacuation. While the detailed planning
process differed among the counties, the first step
generally was to call to the county emergency
operations center (EOC) those people in the county
who were knowledgeable concerning evacuations.
As these people arrived in the county EOC, they
were assigned specific sections of the plan to begin
drafting. The local American Red Cross officials began calculating the number of mass care centersneeded for the evacuees, attempting to identify andmake arrangements for the use of suitable facilities.
County fire and rescue officials began determining
the number of ambulances needed to transport hospital patients and invalids and began locating additional ambulances both within and outside the county. Other groups were identifying evacuation routes,
locating assembly points and arranging transportation for persons without their own, planning the evacuation of hospitals and nursing homes, and prepari ng public announcements for use under precautionary and emergency evacuation orders.
As the plans were developed, county emergency
management directors met with local evacuationzone emergency management directors to informthem of their responsibilities. In five of these six
counties, the evacuation planning was largely centralized at the county level, and local directors wereprimarily responsible in three areas: (1) providing information to the county on needs for equipment,such as ambulances, or on problems with which
they needed assistance; (2) i nforming local
residents of the evacuation plans; and (3) carryingout the evacuation when ordered. The sixth county,
Cumberland County, gave planning responsibility,with the exception of planning for evacuation of

101 9

hospitals and other institutions, to the local directors, reasoning that the local directors could bestplan for their localities and could best carry out aplan they had developed themselves. The Cumberland County Emergency Management Director assisted the local directors and coordinated theirplans. County directors also met with officials from
unaffected portions of their counties and from othercounties to identify areas in which they could provide assistance, particularly in establishing masscare shelters.
As the groups in each county completed the various segments of their plans, the county emergency
management directors reviewed and consolidated
them. By late Saturday night each of the county
directors believed that he could have successfully
carried out a 20-mile evacuation even though detailed plans were not complete. Throughout Sunday
and Monday the counties completed and refined
their plans, and each of the six county plans wasformally printed and issued during the next week.
Several Commonwealth agencies assisted thecounties in preparing their 10- and 20-mile evacuation plans. On Saturday representatives from
PEMA, the Pennsylvania Department of Transportation, the Pennsylvania State Police, the National
Guard, and the Department of Health went to eachcounty to assist in preparing the plans. PEMA
headquarters staff in Harrisburg had the overall
responsibility to assist the counties in developing
plans and to assure coordination of the plansamong the counties. One major function carried out
by PEMA, in cooperation with the Pennsylvania
Department of Transportation, was coordination ofmajor evacuation routes among the counties toavoid situations where two counties, working independently, would plan to use the same road andthereby exceed the road's capacity. PEMA alsosought to prevent two counties from planning to use
the same road to send evacuees in opposite directions.
On Saturday, March 31, PEMA distributed suggested evacuation routes to each of the six risk
counties for their use in developing plans. The
routes suggested by PEMA were selected on thebasis of the general direction each county's evacuees would be moving, the- population density of
the areas the roads served, and the road capacities.
With the assistance of the Pennsylvania Departmentof Transportation, the State Police, and National
Guard representatives in each county, the counties
could use the PEMA suggestions to complete theirdetailed plans, including a procedure for getting
evacuees on and off the major evacuation routes.
Throughout the next several days, PEMA officials,
102 0working primarily through State representatives in
the counties, coordinated the county evacuationroutes, and on April 4 they prepared a map showing
the specific evacuation routes that would be usedby each county. Each county had determined its
evacuation routes before the map was prepared, but
the map provided a coordinated document so that
traffic control agencies such as the State Police
could estimate traffic density expected along specific routes.
The Department of Health representative assigned to each county assisted in planning the evacuation of hospitals and nursing homes. As thecounties identified mass care centers for their evacuees, the Department of Environmental Resources
i nspected the proposed mass care facilities andsampled the water supply of each for impurities.
The Department of Agriculture was prepared to advise farmers in the evacuation zone that before
leaving they should shelter their livestock, reducefood available to cows to slow milk production, andhave water available for the livestock. If the evacuation lasted for an extended period of time, Agriculture was also prepared to work with BRP to try tosafely return farmers to their farms long enough tocare for their livestock. Agriculture was ready to issue sheltering instructions to farmers who chose
not to evacuate. No plans to evacuate livestock
were developed by either the counties or the State.
c. Federal and Other Planning AssistanceAt the Federal level, the Federal Disaster Assistance Administration (FDAA), an agency within the
Department of Housing and Urban Development,
and the Defense Civil Preparedness Agency (DCPA),an agency within the Department of Defense, assisted the State and counties in evacuation planning.
On March 30, 1979, Jack Watson in the WhiteHouse designated Robert Adamcik, the Director of
FDAA's Philadelphia Regional Office, as Lead
Federal Official at TMI and assigned John McConnell of DCPA to assist the State with evacuation
planning. Throughout the accident, Adamcik served
as the Federal onsite coordinator with the State forplanning for the protection and evacuation of the
populace.
The FDAA provided major support to the State inlocating out-of-state emergency equipment, supplies, and personnel needed for the evacuation.
Were it necessary, the FDAA would also havehelped obtain such support. Had a 10- or 20-mileevacuation been ordered, most resources neededby the State and counties were available within theCommonwealth, but certain shortages existed. On
April 2, PEMA's Henderson gave Adamcik a list of
the State's "unmet needs," which included 440 ambulances, 35 doctors, 200 nurses, 1 fixed-wing aircraft, 183 200 blankets, 183 200 cots, and 40 incubators for newborn babies. By April 3 the FDAA,
with assistance from the American Red Cross, hadl ocated sources for most of these needs, although
FDAA daily reports to the White House indicatedthat problems were encountered in obtaining
suffi8,89
cient numbers of blankets and cots.e
On March 28, 2 days before McConnell was sent
to help the State, a DCPA Regional Field Officer,
who was already in the Harrisburg area to assist
PEMA with a training program scheduled for thatday, went to the PEMA Emergency Operations
Center to work with the PEMA staff. On the morni ng of Friday, March 30, at the request of Oran
Henderson, and also before McConnell was
dispatched, DCPA sent two-person teams to Dauphin, York, Lancaster, and Cumberland Counties toassist in evacuation planning. At the same time,
DCPA detailed communications operators with radio
equipment to both York and Lancaster Counties toprovide a communications link with the State Emergency Operations Center. On Saturday, March 31,
as the evacuation planning zone grew to 20 miles,
DCPA assigned communications operators with radios to the four other affected counties. The actualrole of the DCPA representatives in the counties
ranged from assisting the county director in prepari ng the plan to actually writing the plan based on input from the various planning groups within the
county.
On Monday, April 2, at Henderson's request,
DCPA assigned an additional 19 persons to 19 hostcounties in Pennsylvania to assist in developing
plans for reception areas, from which evacuees
would be assigned to mass care centers, and forthe care, feeding, and sheltering of evacuees.
From the start of the accident, local chapters of
the American Red Cross in each county monitored
the events and provided assistance to the county
directors. On Friday, March 30, officials in theAmerican Red Cross National Headquarters inWashington realized that the expanded evacuation
under consideration would be beyond the capabilities of the local Red Cross Chapters. As a result,Daniel Prewitt, the Assistant Director for Disaster
Services in the Red Cross Eastern Field Office inAlexandria, Virginia, went to Harrisburg on Friday tocoordinate the Red Cross response, which wasoriented toward planning for mass care centers.
The following day, at Prewitt's request, the Red
Cross sent 35 trained mass care planners to the
102 1

TMI area, where Prewitt assigned them to the designated host counties to help plan for mass carefacilities.
d. Assessment of Preparedness
ff a general evacuation had been ordered, thecounty and local governments would have had primary responsibility for carrying it out, although
PEMA and the Federal Government would have assisted in specific functional areas. Traffic control
was to be handled by local police with assistancefrom the Pennsylvania State Police and the National
Guard, in cooperation with the Pennsylvania Department of Transportation. Security for the evacuatedarea was to be maintained by the Pennsylvania National Guard. The operation of the mass carecenters in most instances was to be the responsibility of the American Red Cross working with thecounties. The exception was Perry County, whose
evacuees were to remain within the county borders
i n mass care centers which were to be operated by
the county school systems and which required outside assistance only for food after about 48 hours.
Within the counties, planning for the evacuation wasessentially completed by Sunday; details of theplans were completed and the plans formalized
shortly thereafter.
Throughout the incident, State and Federal officials were concerned with the length of time required to carry out a "controlled" evacuation. A
controlled evacuation is one in which advance notice that evacuation will be needed allows positioni ng of support forces, such as the National Guardand the State Police, before the populace is actually
told to leave. Precautionary evacuations are controlled. This contrasts with an emergency evacuation, in which the immediate need for people toleave an area does not allow time to position support forces before the populace begins to evacuate.
While the time required to actually move people inan emergency evacuation will probably be longer
than in a controlled evacuation, it is unclear how
large an evacuation must be before the time required to position support forces will result in ashorter total evacuation time.
Kevin Molloy, the Dauphin County Emergency
Management Director, estimated that a 5-mile evacuation in Dauphin County on Wednesday morning
would have required 6 hours. Oran Henderson
generally agreed with Molloy's estimate and addedthat since Dauphin County had the largest population of the 3 affected counties in the 5-mile zone, it
probably would have taken the longest time to eva-

cuate. 91 Craig Williamson, Henderson's deputy, told
us that based on his judgment, a 20-mile controlled
evacuation on Friday night, March 30, would haverequired about 20 hours. 92 Thomas Blosser, theCumberland County Emergency Management Director, estimated that if a 20-mile evacuation had beenordered Saturday evening, it would have taken 24
hours to complete in that county. He estimated thatby Sunday evening more complete planning would
have enabled a controlled 20-mile evacuation in
Cumberland County to be completed in 12 hours, ofwhich about 8 hours were required for positioning
93
evacuation forces such as the National Guard.
Several county directors we spoke to were reluctant to provide any estimates of evacuation times.
Henderson told us that he too was reluctant to estimate times, explaining that evacuation times would
have depended on many factors. He noted, for example, that an evacuation on the weekend could
have taken less time than one on Monday because
most people do not work on weekends, many
volunteer police and fire and rescue personnel werei n their stations ready to move, and National Guard
personnel were readily available. 94 In addition,
Henderson told us he still does not know how long it
would have taken to evacuate a hospital. 95 YorkCounty emergency management officials hesitatedto estimate times but told us that _ evacuation of
homebound invalids would havetaken more time98
than the rest of the evacuation.
The Pennsylvania Department of Transportation
performed the most analytical estimate of evacuation times. On Sunday, April 1, as the counties were
finalizing their evacuation routes, the Department ofTransportation used this information to estimate thetime required to move the evacuation traffic along
these routes. The Transportation calculations assumed a precautionary evacuation of the total popul ation within the evacuation area, with three persons
i n each car, moving at 35 miles per hour. The calculations were intended only to estimate traffic
movement times and did not include the times required by government organizations to get personnel and equipment in place prior to the order for
people to move. This process produced estimatesof 7 hours to evacuate a 10-mile area and 10 hours
to evacuate a 20-mile area. PEMA officials recognized that actual traffic movement times would havebeen longer had an evacuation been ordered
without warning because all preparations would nothave been completed when it began. At the sametime, since a substantial number of persons had already voluntarily evacuated the area, PEMA officials
97
believed the time estimates could have been high.
The Governor's office was concerned about theability of the State and counties to carry out an eva-

cuation if one were ordered. On Wednesday andThursday, the Governor had been assured by Oran
Henderson, the Director of PEMA, that a 5-mile evacuation could be successfully carried out. After theplanning zone increased, Governor Thomburgh
directed Robert Wilbum, the Secretary of Budget
and Administration, on Saturday, March 31, to independently review the existing plans for a 5-mileevacuation and the plans being developed for the
10- and 20-mile evacuations. Wilburn's review included discussion of the evacuation plans with
Henderson and his deputy, Craig Williamson, andfrequent discussions with officials in the various
State agencies involved in the planning. He obtained information regarding the counties' ongoingplanning efforts from the National Guard representatives assigned to the counties. Wilburn's review
showed that, while the individual county plans differed in degree of specificity, the plans were reasonably good. Further, Wilburn concluded that
PEMA and the other State agencies involved wereadequately addressing problem areas within theirjurisdictions.
By Saturday night Secretary Wilburn was able toassure Governor Thomburgh that a 5-mile evacuation could be successfully carried out and that a
10-mile evacuation could be carried out with a reasonable degree of success and minimal personal
and property loss. Wilbum's review of the 20-mileplanning efforts continued through Saturday andinto Sunday. According to Wilbum, by Sunday
afternoon Governor Thomburgh and his staff, largely on the basis of information obtained from Harold
Denton and Niel Wald, a consultant to the State, hadconcluded that there was little use in planning for a
20-mile evacuation because no accident scenariothat would require a 20-mile evacuation had been
determined. 98 This decision was confirmed by
Chairman Hendrie of the NRC during a meeting with
Governor Thomburgh on Sunday evening. Attention
within the Governor's office was therefore focusedon what Wilburn described as the 10-mile plans with
20-mile consequences: if a 10-mile evacuation had
been ordered, hospitals and other institutions located within the 10- to 20-mile zone might also have
had to be evacuated, since many of the personnel
necessary to run those institutions either lived within
the evacuation zone or would leave voluntarily and99
thus would not be available to operate them.
Staffing in many hospitals in the area was alreadylow because of voluntary evacuations by staff
members.
At PEMA and in the counties, planning for a 20mile evacuation continued after Sunday, primarily
because of the uncertainty about what area would
have to be evacuated, as well as because a 10-mile
102 2

evacuation would likely have resulted in voluntaryevacuation of many people out to 20 miles. The
frustration of the counties at this point is reflected in
the statement by the Director of the York County
Emergency Management Agency that so manychanges were made in the planning zone that eventually officials of that county decided to disregard allstatements made by the State and plan exclusively
for 20 miles.
In addition to Wilburn's review, Lt. Governor
Scranton requested that Robert Adamcik of the
FDAA also independently assess the adequacy ofthe county planning efforts. John McConnell of the
DCPA carried out this evaluation for Adamcik on
March 31 and April 1 when he visited the Dauphin,
Cumberland, York, and Lancaster County EOC's,
observing and discussing the planning process withcounty officials. McConnell said that although thecounty directors were encountering some problems,
the difficulties were being satisfactorily resolved.
McConnell felt that, based on his review, the counties he visited had good overall civil defense setups ime. The Mississauga Evacuation
There are several important questions to consider regarding the effectiveness of evacuation as aprotective action, all of which are important to theplanner. These questions are:
1. How quickly can an evacuation be performed?
2. To what extent does population density and theexistence of facilities such as hospitals, prisons,and nursing homes affect the effectiveness ofevacuation?
3. What is the importance of a good plan, and what
degree of detail should be provided?

The Special Inquiry was unable to provide clear
answers to these questions, but the preceding section does offer informed judgments regarding someof them, at least with regard to TMI. To provide afurther basis for judgment, the Special Inquiry gathered information about the evacuation of 240 000
people from Mississauga, Ontario, Canada's 10thlargest city.
Shortly before midnight on Saturday, November
10, 1979, a Canadian Pacific Railroad (CPR) train
derailed in Mississauga, a suburb of Toronto. The
site of the wreck was a light industrial district about
14 miles from downtown Toronto and about 7 miles
from the Toronto airport. A total of 24 cars of the
106-car CPR train piled up at the wreck site, and fire
broke out immediately. The light from the flaming
wreckage gave the first alert of the accident to thecentral dispatcher of the Mississauga Fire Department, and the first firefighting equipment was at thecrash scene about 2 minutes later.
Of the 24 wrecked cars, 2 were boxcars containing insulation and the rest were tank cars: 11
contained propane, 1 contained chlorine, 3 contained styrene, 4 contained caustic soda, and 3
contained toluene. At 12:10 a.m. a tank car exploded; this was followed by a second explosion about
5 minutes later. The second explosion hurled thetank car about 2200 feet to the northeast. A third
explosion about 5 to 10 minutes later blew a portionof a tank car 200 feet to the south. The explosions
shattered windows within half a mile, and shrapnel
from the explosion set fire to a number of buildings
near the site of the wreck.
Mississauga Fire Chief Gordon Bentley obtained
a copy of the train manifest from the caboose, but it
was an illegible copy. By about 1:30 a.m. he had
obtained a readable copy from CPR headquarters inToronto and confirmed that one of the cars contained chlorine. Upon Chief Bentley's recommendation, Police Chief Douglas Burrows ordered an evacuation of people living within about 2000 feet of thesite in the downwind direction. At 2:10 a.m. about
8000 people living south and west of the crash sitebegan evacuating to a shopping center mall locatedabout 1 1/2 miles northeast of the site.
At 4:00 a.m., following another series of explosions, Police Chief Burrows ordered the evacuatedarea expanded to about 10 square miles around thewreck. By this time personnel from the Chlorine Institute were at the site to offer expert advice. The
Provincial Ambulance Coordinating Centre had been
notified and was assembling ambulances; by 8:00
a.m., 139 ambulances and 300 ambulance workers
had arrived in the area.
Chlorine gas was escaping from the ruptured
tank car, but most of it was swept upward in the
flames of the burning propane. The continuing fireand explosions prohibited attempts to seal the leaki ng chlorine car. Firefighting personnel and equipment from surrounding cities, including a foam
pumper from the Toronto airport, came to the assistance of the Mississauga Fire Department. The PeelRegion Police Department (Mississauga is in thePeel Region) was augmented by police officers from
the Metro Toronto Police, the Ontario Provincial Poli ce, and the Royal Canadian Mounted Police.
By early morning Solicitor General Roy McMurtry,
who is the Provincial Minister responsible for coordinating Provincial emergency measures, Mayor
Hazel McCallion of Mississauga, and Chairman
Frank Bean of the Peel Regional Council were at thescene. These individuals plus Police Chief Burrows
and Fire Chief Bentley formed an ad hoc Emergency

102 3

Operations Control Group (EOCG) at the site command post, under the direction of McMurtry. Whenthe fires continued and the chlorine leak could not
be stemmed, additional evacuation became the only
real alternative.
The emergency plan in effect at the time was al ocal Peel Region evacuation plan prepared about 18
months earlier after a serious fire at a refinery. It
had been used once before in a limited evacuation
following a plane crash near the Toronto airport. In
addition, the police forces relied on a standard
disaster manual.
Shortly after 9:00 a.m., in consultation with othermembers of the EOCG and in view of expert advice
obtained from personnel from the Chlorine Instituteand the Ministry of the Environment, Police Chief
Burrows ordered the evacuation of Mississauga
General Hospital (450 patients) and two nursing
homes (539 persons).
The patients weretransferred to Toronto and to surrounding area hospitals and nursing homes in accordance with the
Ambulance Disaster and Hospital Disaster Plans.
The transfer was completed by 1:15 that afternoon.
After this move was completed, Queensway General Hospital (280 patients) and three more nursing
homes (322 persons) were evacuated.
At 12:30 p.m. on Sunday, the first reception
center at the Square One shopping mail, 1'A miles
northeast of the site, had to be evacuated. The
evacuated area was expanded three more times
during the afternoon, as unpredictable winds carried
the threat to other areas. In each case, except the
emergency evacuation in the morning, police cars
with public address systems were able to alert area
residents prior to the actual evacuation orders. Local radio and television stations gave full-time coverage to the accident. Buses from municipal transit
companies and schoolbuses were used to evacuate
people who had no transportation of their own.
Most evacuees merely checked in at the designatedreception center and then went on to stay withfriends or relatives or in hotels and motels outside
the evacuated area. The reception centers neverhad more than about 3000 people on hand. The
main reception center had to be relocated twice
after it was initially established.
At 7:00 that evening the Mayor of Oakville, aneighboring city, decided to evacuate the OakvilleTrafalgar Hospital and the Oakville Extendicare
Nursing Home (468 patients). This operation wascompleted by midnight.
By day's end more than 2000 persons had been
evacuated from hospitals and nursing homes, andabout 240 000 residents out of a total population of
276 000 had been evacuated from the city of Mis-sissauga. The bulk of this evacuation had been carried out by 6:00 p.m.; it was accomplished in stages
as the winds shifted, endangering additional areas
around the site of the wreck. The evacuated area
covered about 60 square miles. No serious injuries
or mishaps were reported.
Police cordoned off the evacuated area, and only
three cases of looting were reported during the evacuation. The propane fires were allowed to burnout, and the last flames died out by 2:30 a.m. on
Tuesday, November 13. By 8:30 a.m. Tuesday
morning, the leak in the chlorine car was sealed, butby this time 70 tons out of the 90 tons carried by
the car had escaped. By late evening on Tuesday,
110 000 evacuees had been allowed to return home.
However, problems were experienced with the sealon the chlorine car, and it was Friday night before
the remaining evacuees were allowed to return
home.
The Canadian Federal Government is making aformal inquiry into the train wreck and into the subsequent evacuation. The study is being conductedby the Federal Ministry of Transportation and willprobably result in the publication of a White Paper.
I n view of the worldwide interest in the details surrounding the accident and evacuation, the Canadians plan to hold a seminar during the summer or
early fall of 1980 to make available the details of thel essons learned about the state of planning andpreparedness, complicating factors such as hospitals, and effects of the evacuation.
The Province will prepare an emergency evacuation plan next year that can be used for any generalnatural or manmade emergency. The radiation emergency plan which is already in place will probably
serve as a model for this work.
f. Findings and Recommendations
The preceding narrative discusses the efforts of
the State, county, and local governments and theassistance provided by Federal agencies and otherorganizations in planning for 10- and 20-mile evacuations during the TMI accident. The findings of thissection are:

1. The ability to carry out any evacuation around a
nuclear powerplant depends more on the existence of adequate county and local emergency
plans than on the existence of an NRC-approved
State plan. As Oran Henderson, the Director of
PEMA, told us:
I could prepare you the most beautiful State planthat I assure you NRC would approve, but if that

1 024

plan isn't disseminated and the subordinate
county and local municipal plans prepared thatdovetail [with the State plan] and take the guidance in the state plan, you still don't have anything. It's the local government and the county
government that are going to have the capability
to execute any evacuation, if evacuation werenecessary. 102

2. All levels of government were largely unprepared
to respond to the accident at TMI.
3. The NRC's requirement that evacuation of the
Low Population Zone (LPZ) be feasible led State
officials to believe that the planning zone around
TMI was sufficient because it exceeded the LPZ
specified by the NRC.
4. Local emergency plans for TMI did not exist.
While we cannot be sure why localities did notprepare such plans, the probable reasons include: (1) nuclear accidents were perceived as
low probability events for which the localities
were not highly motivated to divert planning funds
and effort, away from higher probability risks inthe area; (2) other major types of disasters (suchas floods) to which the localities were subject
gave sufficient advance warning that detailed
planning had not really been required before; and(3) other types of emergencies, such as fires ortransportation accidents, required only a moreli mited response, for which local agencies werehighly trained and experienced, thus decreasing
the need for formal planning.
5. There was no general agreement during the earlydays of the accident about the size of the areaaround TMI that might have to be evacuated.
This caused confusion within State and county
planning organizations and necessitated a massive effort by them to prepare 10-and 20-mileevacuation plans in the middle of the crisis.
6. Evacuation of institutions such as hospitals andprisons, evacuation of homebound invalids, andthe time required for support forces such as the
National Guard to position themselves are likely
to be critical factors in determining the time required to complete an evacuation.
7. An order to evacuate a specified area around a
nuclear powerplant is likely to have consequences extending well beyond that area.
8. We have uncovered no evidence that several
hundred thousand people cannot be evacuatedquickly and safely. Although the 10- and 20-mileevacuation plans developed during the accident
at TMI were not tested, there was a general consensus within the State and counties, after thefact, that the plans could have been carried out.
We concur in the estimate that, following the

preparation of detailed evacuation plans, evacuation of the area within 10 miles of the plant could
have been accomplished in about 10 hours. Certainly the time required to complete a 10- or 20mile evacuation would have been significantly
higher on Friday than on Sunday because little, ifany, planning would have preceded the evacuation order. Had it been necessary, the evacuation could and would have been completed. The
success of the evacuation in Mississauga further
supports this finding.
9. The plans that existed at the time of the accident
were adequate to carry out a 5-mile evacuation.
Detailed plans were less necessary at TMI for a
5-mile evacuation than for 10- or 20-mile evacuations because of the small number of people, thefew nursing homes, and the absence of hospitals
and prisons within the 5-mile area. We believe
Molloy's estimate that the 5-mile area could havebeen evacuated in 6 hours was reasonable. It
should be noted that conditions such as adverse
weather, which were not factors at TMI, could
have affected the counties' ability to carry out a
5-mile evacuation in that time. An evacuation of
a 10- or 20-mile area would have presented
many more problems requiring detailed planning,as a result of the significantly larger number ofpeople and institutions involved.
The recommendations of this section are:

1. Each Federal, State, county, and local organization involved in emergency response must
developcomplete,
i ntegrated
emergency
response
plans
which
prescribe
theorganization's functions, its emergency organization, and its modus operandi and which assurethat proper information will be obtained anddisseminated by the agency so that it candischarge its responsibilities. Factors importantto the development of these plans include the following:a. The NRC must provide a sufficiently wide
range of accident scenarios so that different
types of responses can be developed accordi ngly. These scenarios must include the rangeof types and amounts of radioactive materials
li kely to be released.
b. The response planned by each organization
should be based on realistic appraisal of the
problems that are likely to be encountered andthe resources that will be needed and available to carry out the necessary response.
c. Federal agencies must have the authority torespond without a State's invitation, based on
the agency's evaluation of whether explicit,
102 5

preestablished criteria have been met, andfunding must be explicitly provided for such
responses. Clear procedures must also beestablished for States to request Federal
assistance.
d. A system which provides, when time permits,
for a series of alerts should be considered.
e. Hospitals, nursing homes, and other institutions (such as prisons) require a tremendous
effort in both evacuation planning and operations. They call for many special resources,
and the time for evacuating an area is significantly extended if such institutions are
i nvolved. All State and local agencies must
recognize these and other special situations indeveloping emergency plans.
f. Emergency plans must routinely be tested to:(1) exercise all notification channels; (2) simul ate the level and temporal response of all
support resources; (3) exercise communication channels during the simulated response
phase, including plant communications trafficand simulated media and public traffic; (4)simulate the evacuation routes and times
required to move people; and (5) drill decisionmakers in realistic, unannounced, and difficult
decision situations.

communications procedures so that plant personnel can provide specific information concerning the extent of the hazard to State,county, and local government officials, coordination of public information releases, and tests
and drills.
e. Funding is required for establishing and maintaining county and local emergency preparedness. We believe funding assistance tocounty and local governments for nuclear
facility emergency planning is necessary for
four reasons. First, many counties near
nuclear power facilities are rural in nature,
have a small tax base, and have limited capabilities to develop meaningful plans. Most
localities in Pennsylvania provided no funds for
emergency management. Second, accidents
at nuclear facilities are low probability
occurrences that likely would not command
priority attention compared to funding for planning for higher probability emergencies. Third,
the response to nuclear emergencies requires
advanceplanning
thanmoredetailed
responses to other types of emergencies.
Fourth, it is not clear that such planning would
be performed in a meaningful manner unlessfunding is provided.
Such funds could come from the NRC,
FEMA, the State, or the utility. We believe theutility should fund the county and local effort
necessary for effective nuclear emergency
planning. Because such detailed planningli kely would not be required for types of disasters other than nuclear, the plans would havea limited specific use related only to the
nuclear powerplant. Also, the people who
benefit directly from the existence of thenuclear plant are the utility's stockholders andthe users of electricity produced by the plant.
Because the hazards and degree of planning
are unique, the beneficiaries are clearly identifi able, and the beneficiaries are not restricted
to the people at risk during an accident, we donot believe the Federal or State Government,i.e., the taxpayers, should be required to fundthe necessary planning.
f. Training of State, county, and local emergency
response personnel must be provided by theutility in areas such as basic plant operations
and the site emergency plans.
g. FEMA, in consultation with the NRC and otherappropriate Federal agencies, should offer
assistance to the States in establishing andcarrying out, if necessary, training programsfor State, county, and local officials having

2. State, county, and local plans for response tonuclear plant accidents must include the following:a. It must be clearly stated that Federal agencies
do not have the authority to order an
evacuation-this is a State, county, and local
authority.
b. The division of authorities and responsibilities
between State, county, and local governments,
as well as between the various State agencies
such as Radiation Protection, the Health
Department, the Agriculture Department, andCivil Defense, must be clearly spelled out.

c. Federal, State, and local relationships must be
clearly defined and the resources that eachagency could provide must be predetermined.
d. Local jurisdictions (those lower than county
level) must develop emergency plans in suchdetail as will assure that their responsibilities
are understood. They must demonstrate theirawareness of the practical demands of anevacuation and the resources that would likely
be required and available. It is likely that most
local and county plans need more detail thanthey now contain. Matters requiring detailed
planning include the size of planning zones,
evacuation routes, designation of host areas,1026emergency
management
planning
andresponse responsibilities.
h. Considering that a large Federal and utility
technical support response will occur in any
emergency that has potential for serious
offsite consequences, the State, county, andlocal plans must consider the resultant impacts
on transportation, food, shelter, and communications, as well as the need for various primary and alternate command centers.
3. FEMA and the NRC should study the Mississauga
evacuation as well as other evacuations of populated areas to determine:a. The extent to which prior planning can
improve the effectiveness of an evacuation.
b. The impact of population density and otherfactors on the effectiveness of evacuation.
4. FEMA should be required to certify the status ofState emergency planning prior to the issuanceof an NRC license, but FEMA's certification musthave NRC input and concurrence and should not
be treated as a separate major Federal action
having significant environmental impact under
NEPA (i.e., while contentions regarding the certification must be permitted in the NRC's adjudicatory proceeding, a separate environmental impact
statement and decisional process should not beestablished for this certification).

6. OTHER PROTECTIVE ACTIONSCONSIDERED BY OFFICIALS
a. Introduction
In the event significant amounts of radioactive
materials are released during an accident at a nuclear powerplant, two protective action options other than evacuation or sheltering are available togovernment
decisionmakers
toreduceapopulation's exposure to radiation. First, if the population is likely to be exposed to significant
amounts of radioactive iodine, persons can be given
a drug called a "blocking agent" to reduce radiation
injury to their thyroid glands. Potassium iodide isone such blocking agent. Second, if food or water in the area become contaminated with radioactive material, action can be taken to prevent theirconsumption.
The following discussion covers the actions taken or considered by the responsible Federal andState agencies with regard to these possible protective actions during the TMI accident.

b. Potassium Iodide
Among the radionuclides that may be released
during a reactor accident are the radioactive
iodines. These are of particular concern from theradiation safety standpoint because they are readily
absorbed by human bodies and accumulate in the
thyroid gland. If a person breathes air containing
radioactive iodine or ingests milk or other food products containing radioactive iodine, the body normally absorbs the iodine, and a significant fraction of
it ends up in the thyroid. Radioactive iodine in the
thyroid can result in benign thyroid nodules or thyroid cancer.
Accumulation of radioactive iodine by the thyroid
can be reduced by use of potassium iodide. Simply
stated, when ingested, the nonradioactive potassium
iodide saturates the thyroid with iodine, so thatwhen radioactive iodine arrives at the thyroid mostof it is rejected and quickly eliminated from thebody. Potassium iodide provides optimal protection
if taken before or immediately after exposure to radioiodine (within about 3 to 4 hours), although someli mited protection will be provided even if it is taken
as long as 10 to 12 hours after exposure.
Potassium iodide has been used medically indoses much larger than those required for thyroid
blocking, in the treatment of asthma and other bronchial conditions, for many years, with few if any side
effects. There is, however, some risk of side effects
associated with taking any drug. For potassiumi odide potential side effects include affecting thefunctioning of the thyroid; nonthyroid-related effects
i nclude swelling of joints, skin rashes, and gastricupset. The side effects can be eliminated bydiscontinuing use of the drug. 104
I n August 1977 the National Council on
Radiation
105
recomProtection and Measurements (NCRP)
mended that potassium iodide be considered foruse during radiation emergencies as a thyroid
blocking agent. The NCRP also noted that the
drug could be stocked at nuclear facilities,
firehouses, police stations, and at similar locations
for ease of distribution in the event of a radiation
107
The NRC failed to follow up on thisemergency.
recommendation; it did not require that potassiumi odide be available for the general population nearreactors. Therefore, drug manufacturers saw nomarket for potassium iodide and did not seek approval from the Food and Drug Administration (FDA)
to manufacture the drug. On December 15, 1978,
partially because of the NCRP recommendation, the
FDA requested drug manufacturers to submit new
drug applications (NDAs) seeking approval to makepotassium iodide in oral dosage forms for thyroid

102 7

108

blocking during radiation emergencies.
This action was unusual for the FDA since normally the
FDA does not solicit NDAs from drug manufacturers.
At the time of the accident at TMI, the FDA had
received no requests for NDAs for potassium iodide
for thyroid blocking; therefore, the drug was notavailable in large quantities. Had the NRC requiredthat potassium iodide be available for the general
population prior to the accident, drug. manufacturers
would have had a market for the drug, the potassium iodide probably would have been manufactured,and, as a result, available during the emergency. In
November 1979 the FDA approved two NDAs from
Wallace Laboratories Division of Carter-Wallace,
I nc., of Cranbury, N.J, for the manufacture of potassium iodide, one in tablet and one in solution form,
for use as a blocking agent during radiation emergencies.
Shortly after the start of the accident at TMI on
March 28, 1979, Dr. Donald Frederickson, Directorof the National Institutes of Health, after conferringwith his staff, advised Secretary of Health, Education, and Welfare Califano that as a precautionary
measure supplies of potassium iodide should beavailable in the Harrisburg area. On Friday evening,
March 30, Secretary Califano directed the FDA toi nitiate steps to make the drug available to the Commonwealth of Pennsylvania as soon as possible.
Toward this end, John Villforth, the Director of
the Bureau of Radiological Health in the FDA, called
Thomas Gerusky, the Director of Pennsylvania's
Bureau of Radiation Protection (BRP), during theearly morning hours of Saturday, March 31, to
determine if the State wanted the FDA to arrange
with a drug manufacturer to make potassium iodide
for the State. Gerusky has stated that before theaccident at TMI, the Commonwealth of Pennsylvania
had attempted to obtain potassium iodide for use in
the event of an accident. BRP found, however, thatpotassium iodide for use as a blocking agent was
not manufactured in this country. (Another blocking
agent, potassium iodate, is manufactured in GreatBritain as a thyroid blocking agent.) 109 Because of
Pennsylvania's prior interest in obtaining potassiumi odide, the fact that trace amounts of radioiodine
had been reported in the TMI area, and the uncertainty about future events at the reactor, Gerusky
i mmediately accepted Villforth's offer.
FDA quickly discovered that local pharmacies did
not have enough potassium iodide on hand to meet
Pennsylvania's needs. As a result, FDA arranged
with the Mallinckrodt Corporation to begin emergency production of the drug.
I mmediately after the Mallinckrodt Corporationagreed to manufacture the potassium iodide, it1028

called in about 50 employees at its Decatur, Ill.,plant to begin production. Mallinckrodt turned sufficient quantities of potassium iodide salt into solution
and bottled more than 100000 ounces to meet theState's needs. An additional 100 000 ounces weresent to Parke Davis Company in Detroit for bottling.
Because Mallinckrodt did not have bottles withdroppers, FDA purchased the medicine droppers
separately from Dougherty Brothers of Buena, N.J.
The cost to the FDA for the potassium iodide wasabout $400 000.
Later Saturday, Gerusky and the Secretary of
the Department of Environmental Resources, Clifford Jones, discussed the potassium iodide decision
with Gordon MacLeod, the Secretary of Health, Emmett Welch, the Deputy Secretary of Health for Administration, and Oran Henderson, the Director of
PEMA. All agreed that the Department of Healthwould be responsible for storing the potassiumi odide and, if necessary, for its distribution.
By 8:00 p.m. Saturday the first 11000 1-ouncebottles of potassium iodide solution, ready for administering, were loaded onto an Air Force cargo jet
for delivery to Harrisburg International Airport. The
first shipment was received by the Department of
Health at about 1:30 a.m. Sunday, April 1. Six more
shipments arrived by Wednesday morning. The
Commonwealth received a total of 237 000 1-ouncebottles of potassium iodide, enough for
10 daily110
doses for more than 10 000 000 people.
The FDA developed, printed, and delivered to theState 250 000 copies of an informational insert,"Patient Information Use of Saturated Solution of
Potassium Iodide (SSKI) for Thyroid Blocking," fordistribution with the potassium iodide. This package
insert described who could take potassium iodide,advised users to begin and stop taking the drug
when told to so do, and identified the side effects
that the drug's users might expect.
On March 31 the Department of Health also printed patient information material entitled "Emergency
Advisory for Protection of the Thyroid Gland fromRadioactive Iodine (1-131)" for distribution with thepotassium iodide. The Department of Health instructions provided general information on shelteri ng, the purpose for taking potassium iodide, when
to begin taking it, how much to take, and how longto take it. The Department of Health insert did notoffer explicit directions for use of the drug, however.
For example, it directed readers to begin taking potassium iodide "at the time of announcement of theimminent likelihood of significant radiation exposure." This required the user's knowledge andjudgment about what a significant radiation exposure was. Also, it advised the user to "drink dosage

Second, the general level of anxiety among thecitizens in the TMI area was extremely high. MacLeod felt that this anxiety (prompted by misinterpretation of announcements that extremely low levelsof radioactive iodine had been found in milk in the
TMI area) created a danger that individuals would
unnecessarily take the drug.
Third, by Monday, April 2, the danger of an explosion from the accumulation of gases within thereactor's containment vessel essentially disappeared, and the possibility of a high level release ofradioactivity was diminishing each hour. The NRC's
Harold Denton offered the Governor assurancesthat the likelihood of an imminent meltdown had decreased and that the leadtime before a release ofradioactive material continued to increase as thedays went on. As a result, the public's need to havethe potassium iodide actually in hand decreased.
Fourth, the Department of Health report refers to
a National Council on Radiation Protection andMeasurements suggestion that after 10 days of taki ng potassium iodide a so-called "escape effect" occurs and prevents the thyroid from taking on further
doses of potassium iodide. A hiatus of several days
must then take place before 114
potassium iodide canbe effectively readministered.
MacLeod reasoned
that, if the radiation hazards, particularly to workers
on the island who could not be evacuated, continued for a period of weeks or months, the workers
would conceivably have had to go through several
cycles of protection versus no protection as they
ingested, discontinued, then reingested the medication. Since no one could predict the onset of a highradiation accident, it seemed more prudent simply tohave the potassium iodide available where it could
be administered within 30 minutes of a substantial
release.
Fifth, as was mentioned before, ingestion of potassium iodide carries with it the small possibility ofside effects such as skin rashes, swelling of salivary
glands, metallic taste in the mouth, soreness ofteeth and gums, gastric upset, shortness of breath,and goiter. Though the risk of serious health effects
was small, the potential for public health problems
encouraged caution in the decision whether to administer the potassium iodide. Since MacLeod believed that potassium iodide could be placed ineveryone's hands in a matter of hours, and wellwithin the leadtime estimated to be available, it
seemed unnecessary to risk even one serious or fatal complication resulting from the drug itself.
Finally, the inappropriate dropper sizes and thecompromised quality of the solution of potassium
iodide also discouraged MacLeod from deciding to
distribute the drug after its arrival.

recommended for appropriate age once a day forten (10) to twenty (20) days (the latter advised by
Department of Health, Education, and Welfare),"which required the user to exercise judgment in deciding when to stop taking it.
Problems began to develop almost immediately
after the Department of Health received the potassium iodide.
I nspectors for the Department
discovered that many of the bottles in the first shipment contained hairlike filamentous material andother particulate matter which indicated the possible1
use of unwashed bottles, poor filtration, or both.
In addition, the white metal cap liners on the bottles
in the first shipment provided an inadequate seal
and were absorbing the fluid, causing some leakage.
Part of the first shipment arrived unlabeled and wasaccompanied by various size medicine droppers
that did not fit the bottles for which they were procured. Furthermore, the droppers yielded only
about half the dosage that had been recommended
by the NCRP.r 2
Jack Ogun, Director of the Division of Drugs,
Devices and Cosmetics in the Department of Health,to whom MacLeod had assigned respo,isibility fori nspecting the drug, immediately discussed these
problems with representatives of the FDA. Ogun
and the FDA officials concluded that, while themedicine's quality was not in full compliance with
FDA standards, it could be effectively administeredwith no health hazards resulting from the deficiencies.
Throughout the next week, Secretary of Health
MacLeod was faced with deciding whether the potassium iodide should be distributed to the populace
or whether the Department should place the potassium iodide in strategic locations in anticipation of
future needs. After discussions with the Governor,
the Lieutenant Governor, Harold Denton, and Dr.
Niel Wald (Professor and Chairman of the Department of Radiation Health of the University of Pittsburgh, who served as a consultant to the Department of Health), MacLeod decided that the potassium iodide should be placed in strategic stockpiles
and not dispensed immediately. According to a document prepared by the Department of Health following the emergency, MacLeod's decision was
based on several factors. 113
First, the National Council on Radiation Protection
and Measurements had recommended that potassium iodide be administered if the anticipated thyroid
dose due to radioiodines exceeds 10,000 millirem.
At the time of MacLeod's decision, the highest cumulative dose projected for any individual within a
5-mile radius of the plant from all types of radiation
was only 80 millirem.
1029

As the potassium iodide was received, theDepartment of Health placed it in a State warehousea few blocks from the capitol in Harrisburg. The
Department then began developing a program for
distributing it to the general populace, should theneed arise. Two plans for handling the potassiumi odide were set forth: (1) for use under emergency
evacuation conditions, when it would be distributed
to the general populace at evacuation receiving
points; and (2) for use in a precautionary evacuation
situation, when it would be positioned for distribution
but not actually distributed to the populace.
On Tuesday, April 3, 1979, a week after the emergency began, the Governor received a recommendation from the Surgeon General, through HEW
Secretary Califano and Jack Watson at the WhiteHouse, that the potassium iodide should be administered to site workers and made available to the
populace within a radius of about 10 miles from theplant. The Director of the National Institutes of
Health (and three of his staff), the Commissioner of
the FDA (and three of his staff), and the Director of
the National Cancer Institute had concurred in the
Surgeon General's recommendation. The Surgeon
General's recommendation was based on these officials' conclusion that for those close to the site thebenefits of administering potassium iodide clearly
outweighed the risks of side effects, because theywould have insufficient time to anticipate exposure.
I n closing, the memorandum from Califano to Jack
Watson that transmitted the Surgeon General's
recommendation noted: "Those in immediate touchwith the local situation should assess these recommendations in light of knowledge about current risks
and aboutthe likelihood of advance warning of115
releases."
Neither John Villforth, the Director of
FDA's Bureau of Radiological Health (who was appointed by Secretary Califano as overall HEW coordinator), nor the HEW representative in MacLeod's
office participated in the recommendations or were
aware of them when they were made.
The HEW recommendation, transmitted by Watson, caused Secretary MacLeod and Wald considerable concern because they believed the "recommendations"were couched more in the language of116
a directive,
even though Califano's memorandum
urged local assessment of the situation. They beli eved the recommendations contained only minimall eeway to accommodate the judgment of health andnuclear officials at the site, who were in the best position to evaluate the dangers. After receiving thisrecommendation, Secretary MacLeod, Niel Wald,and Harold Denton reconsidered and reaffirmed
their original decision not to administer potassium
iodide to anyone, the Federal recommendation notwithstanding.

Wald documented his advice to MacLeod in amemorandum dated April 3, 1979, which stated thatadministration of potassium iodide should be considered for site workers prior to any plant operation
likely to produce an accidental release of radioactive iodine that could result in an absorbed dose of
10 rads or more to the thyroid. Wald advised thatpotassium iodide for the general population should
be located at distribution points, from which it could
be given to the populace for administration within a
few hours after a release sufficient to warrant its
use. He noted that the 20-day duration of potassium iodide treatment proposed by Secretary Califano
was not consistent with the 10-day upper limit referred to by the National Council on Radiation Protection and Measurements. Wald also expressed
concern that, based on the trace amounts of radioiodine reportedly found in local milk, the populace
could misinterpret the need for taking potassiumi odide. Wald's memo provided the final justification
for MacLeod's rejection of the HEW recommendation. r 7
The Department of Health never distributed potassium iodide to anyone. State officials did discusswith Harold Denton shortly after his arrival at TMI
the need to distribute potassium iodide to Federal
officials on site. Denton indicated that he believed
there was no need for such action. Thomas Gerusky of BRP requested potassium iodide from the
Department of Health for use by DER personnel inthe event of a general evacuation, reasoning that
DER personnel would not be able to evacuate because of their radiological monitoring responsibilities. The Department of Health rejected Gerusky's
request on the theory that if the potassium iodide
was made available to DER, it would have to begiven to everyone. Department of Health officials
assured Gerusky that if use of potassium iodide became necessary, it would be given to DER.
I n spite of MacLeod's conclusion and Dr. Wald's
recommendation that the potassium iodide should
be decentrally positioned to speed its distribution,
the entire stock of potassium iodide was kept in theState warehouse in Harrisburg throughout the emergency. Emmett Welch, the Deputy Secretary of
Health for Administration, told us that by the time
the potassium iodide was received by the State, theneed for the potassium iodide had passed and theDepartment no longer saw a need to position it indecentralized locations.r 8
While the State was obtaining potassium iodide,the drug was already available for Metropolitan Edison employees on site. Radiation Management Corporation (RMC), a consultant and contractor to
Metropolitan Edison for the TMI Radiation Protection
Department (and consultant to many other nuclear1030

powerplants in the East and Midwest United States),
provides Lugol's Solution, a potassium iodide solution, for emergency thyroid blockage of workers atthese nuclear facilities, as part of the ongoing emergency medical assistance program. The solution
would be administered, if necessary, under the supervision of a licensed medical doctor.
RMC also indicates to its customers that potassium iodide tablets in the form of expectorants, areavailable on the market as prescription drugs.
Although the therapeutic dose as an expectorant is
twice (or more) than necessary for thyroid blockage,
this form is also suitable for emergency use, and isavailable from pharmacies for approximately $21.00
per thousand.
Some of the Federal officials and Metropolitan
Edison contractors responding to the emergency
had supplies of thyroid blocking agents. One ofMetropolitan Edison's contractors had a supply of
10,000 potassium iodate tablets in packets of 10
each-a 10-day regimen for thyroid blockage for1000 workers. These tablets were available for
emergency distribution under appropriate medical
direction from about April 1. On April 1 FDA headquarters officials had seven 1-ounce bottles ofpotassium iodide solution made up under prescription at a pharmacy near FDA's Rockville, Md.,
offices. This potassium iodide was hand carried tosenior FDA officials in the TMI area with instructions
to take it only when directed to do so by an HEW
official or a competent medical authority on site andthen to share it with others in the area who did nothave potassium iodide. Some NRC personnel onsite also had limited potassium iodide supplies.
c. Food Interdiction
Milk

I n a reactor incident during which there is arelease of radioactive material, milk and other human foods may be contaminated. A principal concern is that radioactive iodine might be deposited on
pastures, taken up by grazing cows, and passedon"9
i n milk to humans. Under the BRP plan,
protective actions relating to milk should be initiated if actual or expected radioiodine levels reach 8300 picocuries per liter (pCi/I) of milk,120 which corresponds
to a 1-rem dose to an infant's thryoid. The FDA
recommends that protective actions be taken if actual or expected iodine levels reach 12 000 pCi/I of
milk, which corresponds
to a 1.5-rem dose to an
121
i nfant's thyroid.
At no time were levels of radioactivity found that would necessitate protective
actions under either the BRP or the FDA guides; the1 03 1

maximum concentration found in any milk sample
was 41 pCi/I,
reported by Met Ed from a sample of122
goat's milk.
Beginning with the evening milkings on March 28,
1979, the Pennsylvania Department of Agriculture, atthe request of BRP, began taking milk samples
directly from farms in the TMI area. This milk sampling program was carried out on a daily basis at
between 7 and 10 farms during the 4-week period
following the accident. As of November 1979 a milk
sampling program is continuing, though the samples
are of packaged pasteurized milk from six dairies in
the area. Agriculture also took forage samples from
TMI area farms.
The highest radioactive iodine concentration
found in any milk sample taken by the Commonwealth was 29 pCi/I. This was found in only
one sample and is well below the levels at which
both the FDA and BRP recommend taking protective actions. As a precautionary measure, however,on March 30 the Pennsylvania Department of Agriculture recommended to dairy farmers in the TMI
area that they put their cows under shelter, awayfrom stream water, and that the cows be fed protected stored feed. Because it was late March andforage grass had not yet begun to grow, most cattle
were already consuming only stored feed, and farmers had adequate supplies of stored feed available
23
in silos 1
This advisory was lifted about 1 month
later when all agreed that the danger was past.
Neighboring States closely monitored milk coming into their States from the TMI area. The State of
Maryland Department of Health and Hygiene carriedout a milk sampling program at 23 farms in northern
Maryland and central Pennsylvania, beginning March
29 and continuing for 2 weeks following the accident. The farms in Pennsylvania, some of whichwere only 3 miles from TMI, held permits to ship
milk into Maryland. The Department of Health andHygiene also sampled some pasteurized milk from
Pennsylvania dairies sold in Maryland retail outlets.
All of Maryland's milk samples were analyzed in the
Maryland Department of Health and Hygiene laboratory in Baltimore. No radioiodine was detected inany samples taken by Maryland above
the 20 pCi/I
124
minimum detectable level established.
The New York Bureau of Radiological Health andthe New Jersey Bureau of Radiation Protection also
tested Pennsylvania milk coming into their Statesand milk from the cows within their own States.
Although there was a press report that the New
York Bureau of Radiological Health detected radioactivity in milk, additional analysis of the samples
showed this to be in error. During this inquiry weheard allegations that several States had taken action to prohibit milk from Pennsylvania from enteringtheir States. Discussions with officials in each ofthese States indicated that none of these allegations
was true. Our inquiry did not reveal any adverse
actions taken by any State against milk from
Pennsylvania.
The FDA actively participated in milk monitoring.
The FDA checked 760 milk samples from TMI area
farms and found trace amounts of radioiodine in 49
samples. The levels ranged from 13 to 36 pCi/I, far
below the 12 000-pCi/I level of concentration atwhich FDA recommends that cows be removed
from contaminated pastures.
The Pennsylvania Department of Agriculture received very few reports of adverse actions being
taken against milk from area farms by milkwholesalers and dairies in the TMI area. They could
confirm only one report of a milk wholesaler's refusing to pick up milk from a local farmer. According to
the Department of Agriculture, the refusal wascaused by the farmer's statement to the media thathe thought his milk was contaminated with radiation.
The wholesaler refused to pick up milk from thisfarmer until his milk could be sampled. After
analysis showed no radioiodine in the milk, thewholesaler again accepted milk from this farmer.
The delay, however, required the farmer to dump
one milking because his milk storage tanks werefilled.
There were also unconfirmed reports thatwholesalers had diverted some milk from normal retail use as fresh fluid milk to use in processed milk
products such as cheese and powdered milk. If thishappened, it had no effect on the farmer, since hewould not receive a lower price for milk because it
was diverted to other uses.
Other Foods

Because the accident occurred before foodcrops in the area had begun to grow, contaminationof food products other than milk was not of great
concern. The FDA did sample some food products
i n the TMI area, however, on Friday, March 30, andanalyzed samples of candy, bread, cheese, pastries,
and ice cream obtained from retail food storeswithin a 20-mile radius of the plant. None of thesamples collected revealed any detectable amountsof radioactivity. If significant levels of radioactivity
had been found, the food simply could have been
removed from the marketplace and further investigation for contaminated products could have continued.
At noon on Friday, March 30, 1979, the U.S.
Department of Agriculture ordered the six federally
regulated meatpacking plants within 5 miles of TMI
to cease slaughtering and shipping meats to avoid

possible radioactive contamination from that source.
Agriculture took this action because there was agreat deal of confusion and uncertainty over the extent of the danger of radioactive contamination. On
Monday morning, April 2, the Department of Agriculture permitted the meatpacking plants in the 5-milearea to resume production based on informationfrom the Pennsylvania Bureau of Radiation Protection that there had been no surface deposits of radioactivity in the 5-mile area and that radiation levels outside the immediate plant area had been negligible.
d. Water Supplies
Several hundred thousand gallons of radioactivel y contaminated water were generated by the TMI
plant early in the incident, and more was generated
i n the following days while technicians brought thereactor to a cold shutdown. State and local authorities were concerned that this water might find its
way into the Susquehanna River and pose a threat
to downstream cities and towns that relied on theSusquehanna River for their drinking water. They
were also concerned that airborne radioactive material from the reactor might be deposited on the
ground, and, either with or without rain, contaminate
nearby private and public water supplies.
On Thursday, March 29, at about 2:30 p.m.,
Richard Dubiel, the Supervisor of Radiation Protection and Chemistry at TMI, called Margaret Reilly of
BRP and told her that the plant urgently needed todischarge industrial wastewater containing "small"amounts of xenon, because its wastewater holding
tanks were almost full. Dubiel stated that if the water was not dumped in a controlled manner thetanks would overflow, dumping the untreated water
through storm drains into the river. Dubiel told Reilly
the amount of xenon in the water was below concentrations that would be allowable under proposals
by the NRC for new plants. There were no existing
discharge standards for xenon for TMI, so Reilly
asked Dubiel if the NRC had approved the discharge
and was told they had.
Reilly approved the dumping, reasoning thatwhen the water got to the river the xenon would
dissipate into the air or be diluted by river water andwould not create a health hazard. Reilly advised
Gerusky that the discharge was being made, butneither notified downstream localities.
This discharge began at about 2:30 p.m., but was
stopped at about 6:00 p.m. by Boyce Grier, theDirector of the NRC Region I office on direction of
NRC officials at the Bethesda Incident Response
Center. By about 8:00 p.m. that evening, NRC offi103 2

cials in Bethesda were satisfied that the State did
not object to the discharge and that the water contained only xenon. By this time BRP had also advised the State of Maryland and downstream municipal users that there was no cause for concern
over the discharge.
Meanwhile, Governor Thornburgh had become
i nvolved in the problem, and NRC officials believed
he wanted to approve the restart of the discharge.
I n fact, the Governor did not know if he had authority to approve the discharge, and he did not learn
that he had no such authority until about 9:30 thatevening when (according to Paul Critchlow, theGovernor's Press Secretary) he was so advised by
Karl Abraham, the NRC Region I Public Information
Officer, who was working in the capitol. For the
next several hours, Critchlow and Abraham argued
over which organization-the NRC or the Stateshould issue the press release announcing therestart of the water discharge. Finally, David Milne,
the DER press secretary, drafted a press statementfrom Clifford Jones, the Secretary of DER, which
was released shortly after midnight. It stated that
Met Ed and the NRC informed the State of an urgent
need to dump wastewater containing small amountsof xenon and that the DER125
had "reluctantly" agreed
the action was necessary.
Shortly after the March 28 accident, the Environmental Protection Agency, in cooperation with DER,i dentified more than 100 sources of drinking water
within 20 miles of TMI. The State of Pennsylvania,
the Environmental Protection Agency, and the Foodand Drug Administration developed and implemented a program for sampling these water sources, including locations on the Susquehanna River wherel ocal communities drew drinking water. At no time
were significant concentrations of radioactive material detected.
If, for example, excessive concentrations of radioactive material had been found in theSusquehanna River, persons normally drawing theirdrinking water from the river would have had to rely
on other sources. Soon after the accident the Stateof Maryland began taking samples from the river because several Maryland municipalities draw drinking
water from the river. By Thursday afternoon, March
29, the Maryland Department of Health and Hygiene
had notified all affected Maryland municipalities to fill
their storage tanks and to keep them full in case it
became necessary to cut off water from theSusquehanna. The municipalities were also advised
to locate possible secondary water sources for use
i n the event the Susquehanna was unavailable foran extended period. Continued and extensive testi ng by the State of Maryland showed theSusquehanna River water to be acceptable for use.
103 3

Testing of water in the Delaware River by New
Jersey State personnel also indicated that no airborne radioactivity had been deposited in thatwatershed and transported as far as the samplingstation at Trenton.
e. Findings and Recommendations
The preceding narrative describes the protective
actions other than take-shelter or evacuation thatwere implemented or considered by officials during
the TMI accident.
The findings in the preceding section on "Shelteri ng and Evacuation Advisories," relating to making
protective action recommendations from Washington and decisionmakers' lack of understanding ofprotective action guides and options, generally apply to this section also. The additional findings ofthis section are:
1.

2.

3.
4.

5.

6.

Radiation exposures projected on the basis ofmeasured or likely releases were a factor of
10 to 200 lower than any protective action
guidelines.
Adequate quantities of potassium iodide forlarge-scale thyroid blocking treatment were
not available in the United States at the time of
the TMI accident. Had large quantities ofradioiodine been released from the TMI-2
plant prior to the arrival of the potassiumi odide in Harrisburg, this protective action
would not have been available to Statedecisionmakers.
State and Federal health officials disagreed on
the length of time potassium iodide could be
effectively administered as a blocking agent.
The State Secretary of Health acted reasonably in not distributing potassium iodide toi ndividuals in the vicinity of TMI despite the
HEW recommendation. However, the potassium iodide should probably have been prepositioned in decentralized locations to speed
its distribution to the populace had the needarisen.
The confusion and Federal and State conflicts
which resulted from HEW's recommendation
to administer potassium iodide to site workers
and persons near the reactor were precipitated by the lack of clear criteria for administering the drug.
BRP and FDA protective action guides for milk
are dissimilar and could have resulted in somesmall degree of confusion and conflicts overthe need to take protective actions regarding
milk.

7.

8.

9.

10.

The package inserts prepared by the Pennsylvania Department of Health for distribution
with the potassium iodide would have required
the public to use their own judgment in determining when to begin taking the drug and how
long to take it.
Uncertainty regarding plant status and thepotential for large releases of radioactivity
were the principal contributors to the concerns and fears of the public and governmental decisionmakers, and led to unwarranted
recommendations or decisions to administer
potassium iodide, close meatpacking plants,
and take cows off of pasture.
The prohibition on Thursday afternoon andevening regarding Met Ed's dumping of industrial wastewater into the Susquehanna River
was not warranted, resulted from a lack ofcommunications between and within the NRC
and the State, and caused a jurisdictional
dispute between the NRC and the State overrestarting the discharge.
There was substantial concern regarding theradioactive contamination of milk, even though
the highest measured levels of radioiodine
were a factor of 200 lower than the protective
action guide.

and use of potassium iodide that are consistent
with Federal guidance and storage requirements.
4. Unlike evacuation, which requires substantial time
to implement, other protective actions should bestrongly considered only if radiation levels or
doses are likely to approach protective action
guides. Such guides are conservatively set tobegin with and generally can be quickly implemented (even after the fact in many cases) so as
to provide adequate protection of public healthand safety. There are also alternatives. For example, if cows are not fed stored feed and water
quickly enough, the milk can be either dumped orprocessed for use at a much later time, after theradioactive iodine has decayed. Therefore, uncertainty regarding plant status and future possible radiological releases should play only a minor
role in recommending these other actions,whereas it may play a major role in the decision
to recommend evacuation. The role that plant
uncertainty should play in the distribution of potassium iodide depends largely on its availability
near the site and the time required to distribute itto the population at risk.

Recommendations 3 and 4 of the section on"Sheltering and Evacuation Advisories," which relate
to the development of clear and commonly acceptable protective action guides (PAGs) and theevaluation of possible actions in the event PAGs arelikely to be exceeded, are supported by the findingsof this section. The additional recommendations of
this section are:
1. The NRC in cooperation with FEMA and HEW
must establish criteria for the storage and distribution of a thyroid blocking agent such as potassium iodide. Specifically consistent guidanceneeds to be developed for the use of potassiumi odide in the total context of nuclear hazards, including nuclear attack as well as reactor accidents; however, prompt attention should begiven to the population at risk in the vicinity of
nuclear plants.
2. The utility must fund the purchase and storage ofpotassium iodide based on the same rationaiethat supports our recommendation to require utility funding of the development of local emergency plans. (See recommendation 2 of "Recommendations and Findings" under subsection 5,
above.)
3. Each State must develop specific criteria andprocedures governing the storage, distribution,

7. RADIOLOGICAL MONITORING EFFORTS
a. Introduction
On Wednesday, March 28, 1979, at 6:50 a.m.,
Met Ed announced to all persons at the TMI plantthat there was a radiation problem on site and at
7:24 a.m. announced a general emergency, signifying that there had been or might be an extraordinary
release of radioactivity off site. In accordance withestablished and practiced procedures, both of theseannouncements were promptly telephoned to
Pennsylvania State radiation specialists and to an
emergency response team of radiation experts at
Brookhaven National Laboratory (BNL), a U.S.
Department of Energy facility in New York about 150
miles from TMI. Those two calls, plus calls to the
NRC and detection later in the morning of above
normal radiation levels in areas away from the plant
property led to extensive efforts by Met Ed andFederal and State agencies to determine the extent
of the radiation hazard to persons in the vicinity of
TMI.
These efforts required the measurement of radiation levels and concentrations of radioactive material
i n air, water, milk, and other food products in anarea extending more than 20 miles in all directions
around TMI. In Pennsylvania, thousands of radiation
measurements were made at nearby Goldsboro and1034

Middletown, and at York, Lebanon, Hershey, Carli sle, and many points in between. The neighboring
States of Maryland, New Jersey, and New York
examined the possibility that TMI-produced radioactivity would end up within their respective borders.
Detailed information on these radiological monitoring
activities and their results are presented in the section on "Radiological Releases" and in Appendix 111.7
of this report. The following provides an overview of
the agencies involved, describes generally what kindof measurements were made, and offers several
findings and recommendations based on Government agencies' responses to the TMI accident.
b. Overview of Agency Participation
A wide spectrum of organizations with various
responsibilities performed radiological monitoring
functions during the TMI accident. Under its reactor
operating license, Met Ed is charged with determini ng offsite consequences of radioactive releases sothat it can recommend protective actions to theState and local governments. The NRC supported
the utility in this task and strove to meet its own
statutory obligation to assure protection of the
public's health and safety.
The Commonwealth of Pennsylvania, having
direct responsibility for the protection of its citizens,
had previously assigned to its Bureau of Radiation
Protection (BRP) the task of obtaining and evaluati ng radiological data and recommending required
protective actions. Most of BRP's 19 professional
staff members were involved full time in response to
the TMI accident. BRP relied heavily on information
and analyses on monitoring provided by Met Ed, the
NRC, the U.S. Department of Energy, the Department of Health, Education, and Welfare, the U.S.
Environmental Protection Agency, and the State of
Maryland. ft also obtained information from its own
sampling and measuring activities, analyzed many ofthe milk and environmental samples in its own laboratory facilities, and maintained a comprehensive
awareness of the plant's status, the radiologicalreleases, and the potential radiological effects of theaccident. The neighboring States of Maryland, New
Jersey, and New York, having responsibilities forprotection of their own citizens, monitored theenvironment within their respective boundaries andsampled milk from Pennsylvania that was intended
for consumption in those States.
Agencies of the Federal Government took extensive part in the radiological monitoring effort. The
Department of Energy (DOE) provided the earliest
and greatest radiological response. Initially, theDOE Region I office provided a Radiological Assistance Program (RAP) team, along with technicalmembers from BNL, in support of the Commonwealth of Pennsylvania. This support was provided in accordance with the DOE program for implementation of the Interagency Radiological Assistance Plan (TRAP) and the interagency agreement
between DOE and the NRC. At the peak of DOE's
radiological activities at TMI, there were RAP teams
from three of the eight DOE Regions, along withtechnical members from seven contractors, involved
i n making measurements. 126 DOE also provided
aerial monitoring and meteorological assistance.
The Environmental Protection Agency (EPA) andthe Department of Health, Education, and Welfare(HEW) were also major Federal participants. DOE's
assistance at TMI had been requested by BRP and
the NRC. The involvement of EPA and HEW wasl argely at their own initiative. They responded later
than DOE, and their participation stemmed from a
combination of their own health and safety responsibilities under their enabling statutes
and en%27
couragement by the White House.
By Sunday
following the Wednesday accident, those threeFederal agencies (DOE, EPA, and HEW) had moved
nearly 170 trained professionals into the TMI area toperform radiological monitoring. The buildup anddecline of these resources is illustrated in Figure III14.
Other agencies played important support roles.
Pennsylvania's Department of Agriculture collectedmilk samples from farms near the damaged reactor.
A U.S. Coast Guard helicopter moved monitoring
personnel and equipment from Brookhaven National
Laboratory on Long Island, N.Y., to the TMI area.
The U.S. Department of the Interior diverted communications equipment normally used in fighting
forest fires to use at TMI. More than 200 portable
two-way radios were flown in from the firefighting
center in Boise, Idaho, for use by monitoring personnel so that the results of measurements taken
anywhere in the area could be rapidly sent to acommand center for compilation, providing a current
composite view of the TMI radiological environment
at all times.
c. Brief Description of Offsite Radiological
Monitoring
Early on Wednesday morning a high radiationlevel was detected by the radiation measuring instrument at the top of the TMI-2 reactor building. A
calculation, based on that radiation level and an assumption about how fast radioactive gases were103 5

170 --1

U.S. ENVIRONMENTAL

PROTECTION AGENCY (EPA)
US. DEPT. OF HEALTH, EDUCATION

160 -&WELFARE (HEW)U.S. DEPT. OF ENERGY (DOE)

150 -

140 -

130

120 -

110 -

3-28

3-29

3-30

3-31

4-01

4-02

4-03

4-04
DATE

4-05

4-06

4-07

4-08

409

410

4-11

FIGURE 111-14. TMI Radiological Monitoring Personnel (DOE, HEW, and EPA)

1036

4-12

n

leaking from the reactor building, indicated that the
576 residents of the village of Goldsboro, about amile away, were being exposed to a radiation levelof 10 rem (10 000 millirem) per hour. If that was theradiation level, and if it remained constant for 30
minutes, people in Goldsboro would receive 5 rem,or 5000 millirem, a dose which under the protective
action guide established by Pennsylvania would require their evacuation. Because of the high radiation level that had been calculated, an evacuation
alert was called. In view of the uncertainty about
the assumptions used in the calculation however,Gary Miller, TMI Station Manager, requested a State
Police helicopter to take a pair of Met Ed monitoring
technicians across the river to Goldsboro. In fact,
the technicians took a longer route to Goldsboro bycar. Another group made radiation measurements
at the west side of the island. All teams made radiation measurements and found nothing unusual atthat time.
A couple of hours later, however, at about 10:30
a.m., the Met Ed monitoring personnel found low
l evels of radiation (about 3 millirem per hour) nearGoldsboro. That positive indication of a release ofradioactive material from the damaged reactor triggered extensive efforts to find out just how muchradiation people in the area were receiving and to
decide what actions, if any, should be taken to protect those people.
Earlier in the morning the BNL RAP team had
been placed on standby alert, but at 11:18 a.m. BRP's
Reilly requested BNL's Charles Meinhold to send
the team from New York to the site.128 This
seven-person team flew by Coast Guard helicopter
to the TMI area, arriving at about 2:30 p.m., andpromptly began collecting air, soil, and vegetation
samples and making field radiation measurements.
A second BNL RAP team of five persons arrived inHarrisburg at about 1:30 a.m. on Thursday morning,
primarily to serve as a relief team. Initially the RAP
teams worked out of Gerusky's BRP offices in
downtown Harrisburg, but on Thursday the RAP
teams moved their base of operations to the Capital
City Airport, joining with other DOE personnel toform a DOE Command Post. The airport was closer
to TMI and the decision to locate at the airport
helped improve communications between persons in
the field and persons at the base.
Both the BRP and the NRC fielded their first environmental monitoring teams late Wednesday
morning. Until that time, Met Ed personnel had done
essentially all of the field monitoring. The total effort
by Met Ed, BRP, and the NRC on Wednesday was
carried out by about a dozen persons.

103 7Participation by other Federal agencies during
the first 2 days was only modest. The EPA, for example, took daily instead of its usual weekly air
samples in Harrisburg, Pa., Wilmington, Del., andWashington, D.C. The EPA also took water samples
from the Chesapeake Bay and the lower
Susquehanna River. HEW developed a strategy forfood and water sampling and began actually sampling and measuring on March 29.

During these first 2 days a total of up to about 40
DOE specialists using many sophisticated radiation
measuring instruments, meteorological instruments,
computers, helicopters, fixed-wing aircraft, aerial
photographic cameras, two-way radios, and surface
vehicles participated in evaluating radiation and radioactivity levels out to many miles from TMI. The
strategy for the offsite radiation monitoring was simple: Find the radioactive material, measure it, andthen compile and evaluate the measurement data.
The task of finding the radioactive material at
ground level was simplified considerably by having
good guidance on where to look. That guidancecame at the arrival early Wednesday afternoon of aU.S. Department of Energy Aerial Measurement
System/Nuclear
Emergency
SearchTeam(AMS/NEST) from Andrews Air Force Base near
Washington, D.C. The team's helicopter, and asecond helicopter that arrived from Las Vegas earlyon Thursday, were equipped with radiation measuri ng instruments. This AMS/NEST group had been
mapping normal levels of radiation near nuclear
power reactors for several years. The same groupalso assisted Canadian authorities in 1978 in locati ng a highly radioactive Russian satellite that fell in aremote area of Canada.
From the period of March 28 through April 15, the
AMS/NEST unit made 72 flights at TMI. The team
was particularly useful in tracking and locating theboundaries of the "clouds," or plumes of invisible radioactive gases emitted from the plant through theuse of their radiation monitoring equipment. On occasion, when meteorological conditions were right,
the teams were able to track the radioactive plumeout to 20 miles from TMI because their monitoring
equipment was very sensitive and could measurevery low levels of radiation.

With the heightened concerns on March 30, thelevel of effort by all of the Federal agencies involved
i n the radiological monitoring effort increased substantially (refer to Figure 111-14). The NRC requested
and obtained additional DOE support for its land
survey teams, EPA brought in a monitoring teamand laboratory analysis staff to work closely with
the State, DOE support of the Commonwealth of

Pennsylvania was increased, and HEW increased its
personnel in the area dramatically.
Incoming teams were equipped with radiation
measuring instruments, including those to be used inmeasuring exposures to team members. Such instruments, called personnel dosimeters, were alsoavailable locally for use by the National Guard andothers. Many of the National Guard's personnel dosimeters, however, were designed for measurementof the high levels of radiation associated with nuclear warfare and were of no value for indicating the
TMI low level radiation encountered by individuals.
With the increase in numbers of persons andagencies participating, there was a need to coordinate the monitoring efforts. Gerusky of BRP asked
DOE to take the lead in this effort. Beginning Friday
evening, representatives of the agencies performing
monitoring met daily at 5:00 p.m. at the DOE Command Center at the Capital City Airport to pool theirdata and plan the next day's activities. DOE undertook the task of compiling and summarizing the data
into a form that was useful to decisionmakers. The
information developed was given to the Commonwealth of Pennsylvania, the NRC, and other interested parties, and was used by the NRC, DOE,
EPA, and HEW to estimate the maximum individual
exposure among the public, the cumulative population exposure, and the health effects resulting fromthe TMI accident.
By Monday, DOE, EPA, and HEW radiation specialists were at TMI en masse. Radiation measurements were being made in all directions out to 20
miles and more from the reactor. HEW had morethan 200 radiation measuring devices carefully located on a grid pattern within the 20-mile radius.
The NRC, Met Ed, EPA, and BRP had measuring
devices at selected locations. EPA had used aerial
photography to identify 465 dairies within 25 miles
and had selected 9 dairy farms from which to obtainsamples to complement milk sampling programs already underway by BRP, HEW, and the State of
Maryland. Water supplies were being analyzed by
the NRC, BRP, HEW, EPA, DOE, and neighboring
States. Air sampling instruments and external radiation measuring instruments were located in concentric circles of from 3 miles to 6 and 7 miles fromthe plant and in nearby towns. Teams of radiation
specialists with portable instruments and two-way
radios were in contact with the DOE central command post at the Capital City Airport where monitoring data was displayed using transparent overl ays on large maps of the area. To sum up, this effort certainly resulted in a comprehensive radiological monitoring program. Once in place it could haveadequately responded to higher offsite radiation lev-els and to much larger releases of radioactive material than were experienced at TMI.
Buildup of the radiological monitoring efforts was
extensive during the first weekend following the accident. Intensive efforts continued at a high level forabout a week and then rapidly diminished following
Governor Thornburgh's announcement on April 9that pregnant women and preschool-age children
could safely return to the area.
On April 13, the White House designated EPA thelead Federal agency for long term radiation monitori ng at TMI. EPA had the responsibility for collecting,collating, and maintaining all the various radiation
monitoring data that were developed by the NRC,
DOE, EPA, HEW, and others. It was recognized thatthese data were critical to understanding not only
what had happened at TMI, but also its environmental effects and its consequences for public health.
EPA, as opposed to DOE, was selected for the task
i n recognition of its statutory mandate to protect air
and water quality and in recognition of the public's
awareness of EPA's principal mission of controlling
environmental pollution. The public, on the other
hand, identified DOE with energy development.
White House staffer Eidenberg has explained that
selection of EPA as lead Federal agency for longterm radiation monitoring did not reflect a lack ofconfidence in the technical competence of DOE and
HEW. 129 Long term monitoring by EPA, with limited
assistance from DOE, is underway and is expected
to continue through the TMI cleanup process.
d. Findings and Recommendations
The preceding narrative has described the natureand the extent of the participation of each of theagencies involved in the radiological monitoring effort. The findings of this section are as follows:
1. Because of the high radiation levels in the reactor
building, it was clear by 8:00 a.m. on March 28
that there had been a radiological accident ofserious potential consequences at TMI. Yet the
DOE AMS/NEST was not requested by the NRC
until 11:00 a.m., and the DOE RAP team was not
requested by BRP until after 11:00 a.m.

2. The radiological response effort was more thanadequate and likely would have been adequate
for an accident of much larger offsite consequences.
3. There was recognition in Washington that a single Federal agency should be assigned the lead
for long term radiological monitoring and EPA

1 038

was eventually given this assignment. This assignment was consistent with EPA's statutory
responsibilities to protect the environment andwith the public's perception of normal EPA activities.
4. There was a lack in the TMI area of immediately
accessible personnel monitoring devices able toi ndicate radiation doses below one rem. This
could have affected the emergency response actions of the State Police and the National Guard
had radiological releases necessitated an evacuation.
5. While not substantially affecting the radiologicalresponse, there was some initial duplication of effort in radiological assessments and there weresome early delays in obtaining results because
suitable locations for radiological monitoring andradio relay stations had not been designated prior to the accident.
Consideration of the TMI radiological response
suggests that the following recommendations would
lead to a more effective and efficient operation in
the event of a reactor accident with substantial
offsite radiological consequences:
1. DOE must be the lead agency for coordinationand implementation of a prompt, large-scale emergency radiological monitoring response because it is already operationally equipped forsuch a function. However, the EPA should be thel ead agency for long term, low level, followup
monitoring; HEW, with its broad responsibilities
for protecting public health, should be the leadagency for determining the long term health effects of the accident.
2. FEMA must assure that personnel dosimetry
equipment capable of measuring and indicating
both low and high radiation exposures is available
for those involved in conducting evacuations andsecuring the evacuated areas. These include theState Police, fire personnel, and the National
Guard. FEMA must also assure that training isprovided in the use of this equipment.
3. RAP and AMS/NEST units must be promptly
dispatched by DOE at the onset of a potentiallyserious radiological incident, even without waiting
for an invitation or request from the State or the
NRC.
4. Radiological monitoring and radio relay positions
must be preplanned by the utility in cooperation
with the NRC, DOE, and the State, and should bebased on land use, terrain, accessibility, and other considerations.
1039

8. I NSTITUTIONAL COMMUNICATIONS
a. Introduction
This discussion addresses three elements of thecommunication process (information selection,transmission, and assimilation) in the context of the
TMI accident, with emphasis on interagency communications. In so doing, it attempts to analyze theeffectiveness of institutional communications during
the course of the emergency response to the TMI
accident.
b. Notifications
Metropolitan Edison Company's emergency procedures for TMI-2 required plant operations personnel to notify the Pennsylvania Emergency Management Agency (PEMA) and, "as necessary," the NRC
Region I office in King of Prussia, Pa., the Dauphin
County Office of Emergency Preparedness, theDepartment of Energy (DOE) Region I Radiological
Assistance Program (RAP) at Brookhaven National
Laboratory in New York, various utility management
representatives, and the Hershey Medical Center, in
1 30
These notifications, both of a site
Hershey, Pa.
emergency and of the subsequent general emergency, were easily made over commercial telephoneli nes on Wednesday morning soon after the accident. However, the NRC Region I answering service was unable to promptly contact the NRC Re1gion I Duty Officer or the Deputy Region Director. m
One organization on the utility call list, the Hershey
Medical Center, was deliberately not contacted.
Clarence Deller, the PEMA duty officer, who was
automatically notified by PEMA of Met Ed's call,phoned the duty officer of the Bureau of Radiation
Protection, William Dornsife, at his home at 7:05
a.m. Deller also attempted to contact the Emergency Management Agencies (EMAs) of the three counties within 5 miles of TMI (Dauphin, York, and Lancaster), other State Agencies, and nearby States toi nform them of the site emergency. Deller was notable to reach the York County EMA by phone andasked the Lancaster County Director to relay the information to York by teletype, since, in addition tocommercial telephone connections through county
courthouse switchboards, county EMAs have permanent teletype connections with PEMA and witheach other. This 132
message reached the York County
EMA at 7:27 a.m.
BRP duty officer Dornsife called Margaret Reilly,
Chief of the Division of Environmental Radiation,

who in turn called Thomas Gerusky, the Director of
the Bureau of Radiation Protection, with word of theaccident. In accordance with the BRP emergency
plan, Dornsife then established contact with the
TMI-2 control room. Gerusky was the first BRP
employee to arrive at work that morning, getting
there at about 7:25 a.m., and, again following the
BRP emergency plan, he recontacted the TMI-2
control room. This line remained open for about 2
weeks and became the primary direct means ofcommunication between the Commonwealth and theutility. 1
Soon after the NRC Region I switchboard was
opened at 7:45 a.m., a telephone line was established between the TMI-2 control room and the
NRC Region I office. This line was also kept open
continuously. The NRC Region I staff contacted the
NRC Headquarters and established a relay for information between the plant and Bethesda. The NRC
Headquarters staff notified many other Federal
agencies in accordance with an emergency call listthat had been developed.

During this preliminary notification process eachof the elements of the communications process was
simple and, with the exception of the problem inreaching the NRC Region I office, the process
worked quite well. The information selected fortransmission was very limited, but it was sufficient
to alert government officials to the problem as perceived at the plant. Oran K. Henderson, the Director of the Pennsylvania Emergency Management
Agency, for example, noted at the time that, "Theygive us the bare minimum, and that's what wewant." 1 34 These transmissions were made almost
entirely over the commercial telephone system,
which functioned very satisfactorily. Assimilation of
the information and initiation of actions on the basisof that information were prompt.
c. Technical Communication Between
Agencies
After the initial notifications, interagency communications became highly technical. In a nuclear
powerplant, as in any large facility of such complexity, a very specialized vocabulary develops to identify rapidly and unambiguously any component of thesystem. Even a technically sophisticated individual
normally requires substantial explanation of terms incommon use at the plant. In the emergency communication chains established at TMI, wherecharacteristically there were several intermediaries
between the source of the information and its user,
104 0

the opportunities for misunderstanding werenumerous. The selection of information to betransmitted and the significance given to it by thereceiver were markedly influenced by the previous
experience, training, and expectations of the individual. For example, plant operating staff did notcommunicate indicative temperature and pressure
data to the NRC because either they did not appreciate the significance of the information or they believed the data invalid.
For 2 days the open telephone lines from theplant to the BRP, the NRC Region I office, the NRC
Headquarters in Bethesda, and the utility headquarters functioned as the principal channels of communications. A response team from the NRC Region I office, arriving at the plant on Wednesday
morning, was soon manning the telephones from theplant to the NRC Region I office, and the NRC Headquarters. Communication with the plant became
physically more difficult when control room radiationnecessitated the use of respirators. The telephone
communications between the plant and the State
were supplemented by offsite briefings of State officials by both utility and NRC staffers.
The DOE Radiological Assistance Program (RAP)
team, which was aiding the State in its radiologicalmonitoring efforts, established its base of operations
with the State's Bureau of Radiation Protection inHarrisburg, so contact with the BRP was personto-person rather than by phone. The AMS/NEST
group that had been requested by the NRC locatedits headquarters at the Capital City Airport in New
Cumberland, Pa. and used the manager's office,where there was an adequate number of telephones
available, for its center of operations. After the telephone company installed telephone lines and equipment, the team moved on Thursday to the Statehangar at the airport, where DOE also establishedits local command post. The AMS/NEST continued
to use the telephone to relay its data to the NRC, to
DOE Headquarters, and to the RAP team in Harrisburg.
During the 2-day interval from Wednesday to Friday, the principal means of communication among
all organizations remained commercial telephoneli nes. There were, of course, face-to-face communi cations between utility personnel and NRC
representatives at the plant; between the DOE RAP
team and the BRP in the BRP office; and among theutility, the NRC, DOE, the Governor, and other State
officials at the State Capitol. At both the NRC
Headquarters in Bethesda and at the State Capitol
i n Harrisburg, however, the insufficient and varying
data they were receiving gave rise to concern thatthe right information was not getting to them.

d. Particular Communications Problems
Encountered
Every element of the communication process encountered difficulties during the course of the accident. Because of the limited number of telephonelines into the TMI plant, it was sometimes difficult tocontact plant personnel. Babcock & Wilcox (B&W,
the reactor vendor), for example, was unable tocontact the plant for extended periods on Wednesday. 135 Occasionally, unattended lines which were
supposed to remain open were disconnected; 136reestablishing the connection could be both time
consuming and frustrating.
Too, the circumstances surrounding Thursday's
discharge of the slightly contaminated industrial
wastewater into the Susquehanna River illustrate
both a lack of complete information and failure to
assimilate and recognize the significance of the information. Both problems resulted from poor communications and both providing clear examples ofhuman failures, not mechanical ones.
The protracted nature of the accident, the lack ofconfidence in the utility, and the general perceptionthat the plant's control of radioactive releases had
substantially improved set the stage for the Friday
morning release of radioactivity into the atmosphere.
Shift Supervisor Floyd's description to PEMA of therelease as "uncontrolled" was soon followed by an
NRC recommendation for evacuation. This recommendation was subsequently reversed, but not before the public was informed of the evacuation possibility.
The concern and confusion related to these
events produced such a volume of telephone trafficthat the local exchanges were overloaded, 137 andmost of the lines being used for the TMI response
were connected through these local exchanges.
The consequent loss of key telephone connections
created a great deal of consternation among
Government officials participating in the response
effort because it effectively isolated those responseorganizations which had not established dedicatedtelephone lines or were not maintaining open lines.
While some radio communications were used during
this chaotic Friday morning, they were ineffective,
not only because there were too few radios, butalso because, in some instances, terrain and buildings interfered with transmission.
The details of the events leading to the evacuation advisory for pregnant women and young children are provided in the previous section, "Sheltering and Evacuation." One aspect of this story, however, seems strongly influenced by communications
problems. At 9:15 a.m. on Friday morning, PEMA's
104 1

Henderson received a telephone call from the NRC's
Collins in Bethesda recommending evacuation out to10 miles. Henderson then notified BRP's Gerusky of
Collins' call. Gerusky responded that BRP was notaware of any information that would justify an evacuation and said that he would look
into the matter13
and get back in touch with PEMA. e Before getting
confirmation or advice from BRP, however, Henderson notified Molloy, Dauphin County Coordinator, ofthe strong possibility of a 5-mile evacuation order
within the next 5 minutes. Molloy immediately madea radio announcement alerting the public to theevacuation possibility, causing distress and confusion which might have been averted, either byi mproved communications channels and information
flow from the plant to the NRC Headquarters or byi mproved communications between BRP and PEMA,
as by the presence of a senior BRP official at the
PEMA Emergency Operations Center.
It should be said that, although the emergency
communications at the PEMA center were activatedon Wednesday morning, emergency teams from thevarious State departments were not physicallypresent at the center until late Friday morning. Evenat that time, the Department of Environmental
Resources representative at the center was not an
official from BRP and did not have nuclear training.)
e. Communications Improve After Friday
A number of organizational and operational actions that altered the communications process forthe remainder of the emergency response were taken or at least begun on Friday.
Coordination• The President assigned coordination of theFederal response
to Jack Watson of the White
139
House staff .
• A senior NRC task force headed by Harold Denton established a base of operations at the plantsite; Denton represented the President andserved as official NRC spokesman.
• Governor Thornburgh assumed direct control of
emergency response and public information in
Pennsylvania. 140
Hardware• Direct phone lines were installed connecting theplant, the NRC,
the Governor's office, and the141
White House.

• DOE moved its mobile field communication sys-

tem from Nevada and provided
additional com142
municators and field personnel.
• Dedicated telephone lines connecting PEMA
directly with 143
the EMAs in the six risk counties
were ordered.
• DCPA installed radio equipment in the six counties to provide backup communications
among
144
the emergency management agencies.
Personal Communications• DCPA and FDAA staff were brought in to work

directly with State and local emergency management personnel in planning 10-mile and 20-mile
45
evacuations.
• DOE conducted daily radiological monitoring
coordination meetings at the Capital City Airport
for all governmental agencies involved in monitori ng. 46• At least two of the counties set up rumor control
phones with special numbers. 147,148• The State, assisted by the FDAA, established its
rumor control center during the following
149
week

These actions ultimately produced a substantialchange in institutional communications. Direct communications between the information sources andthe evaluators became more common, and basic
data became available to decisionmakers. The potential for error in data communications shranksince the key communicators were now more
broadly knowledgeable people. Improved interagency communications narrowed the divergence of purported facts.
All official pronouncements eventually were centralized through Governor Thornburgh, Harold Denton, or the White House, and the rampant production of unsupported rumors was tamed. Unfortunately, the decision to implement this centralized
i nformation process also served to close the normal
official communication channels to the local areas
which, as a result, became almost totally dependent
on the news media for information.
The counties were unable to get information fromthe State throughout much of the accident. PEMAi ssued situation reports to the counties but communicated little if any substantive information aboutplant status.
This situation was aggravated by two factors.
First, before Friday, and as required by the Stateemergency plan, BRP had routinely provided plantstatus and radiological monitoring information to

PEMA, which in turn passed the information on to
the counties and to others. These reports largely
reflected "no change" in previous status reports, because radiological releases were not large and theplant status was not well understood. After Friday
morning, however, the Governor stated that hewould be the sole spokesman within the State.
PEMA interpreted this statement to mean that nothi ng other than planning information was to be communicated to the counties by PEMA, and so confusion about releases and the plant's stability escalated. The county organizations, bombarded with reports of what had been heard on radio or television,deluged with questions about the information's validity, and cut off from official information sources,were unable to respond effectively.
The additional telephone and radio communications equipment installed as a result of Friday's difficulties and, perhaps more significantly, the assignment of PEMA and DCPA personnel to the counties
to assist county emergency coordinators indeveloping detailed 20-mile evacuation plans, constituted a framework for some effective communication between the State and local agencies. In thearea of evacuation planning, that framework appears to have supported very effective communications; in the area of plant status, it did not.
Within the State, technical information generally
flowed upward from its source to the Governor's office. Little information moved laterally from agency
to agency. The BRP supplied neither liaison personnel nor meaningful status reports to PEMA. The
NRC provided "preliminary notifications of events orunusual occurrences," called PNOs, to the press
and to the Governor's office; PEMA, however, wasunaware of them for the first week of the emergency, and the PNOs were not sent to the counties until
after PEMA began to receive them.
After Friday the NRC provided essentially all information about plant status to the Federal andState Governments and to the public. This information reflected the caution and pessimism properly
associated with a regulatory environment, but it is
not clear that such deliberately pessimistic information should dominate public information in an emergency. After Friday, however, there were no alternate sources from which a different perspective
could be obtained.
Confirmation that the bubble was diminishing andthe visit of the President and Mrs. Carter to thepl ant on Sunday marked the beginning of a calmer
but still very cautious period. Ample communications equipment was available so the extensive contingency planning for evacuation and for plant support could be continued with minimal difficulty.
104 2

Isolation of county governments from technicali nformation, however, continued, but a gradually reduced level of public apprehension made this isolation less important as time went on.

6.

f. Aftermath
During the long term recovery period, available
means of communication reverted to preaccident
status. By the end of April the additional communications systems, such as the dedicated telephonelines between PEMA and the county emergency
management agencies, the DCPA radio links withthe counties, etc., had been withdrawn. 150,151
Actions have been taken since the accident tomake permanent improvements. The NRC, for example, has required the nationwide installation of
dedicated lines from each licensed nuclear reactor
plant control room to the NRC Headquarters. It isproviding each NRC regional office with a small
short-range portable field radio communications
system for use by its emergency response team.
Headquarters and regional emergency operations
are staffed 24 hours a day.

The Act or Process of Communicating
7.

8.
9.

10.

g. Findings and Recommendations
The preceding discussion has illustrated thetypes of communications problems which were encountered during the TMI emergency response.
The findings of this section are listed below.
Communications Systems
1.
2.

3.

4.
5.

The commercial telephone system functioned
satisfactorily during the initial notifications.
The commercial telephone system using dialup connections was not satisfactory for continuing technical communication during the
emergency.
The telephone companies functioned well in
response to numerous requests for installationof lines and equipment, but there was nocoordinated planning for either telephone orradio requirements. Such planning could haveaccelerated the process of making communication equipment operational.
In times of public confusion and concern,
overloading of local telephone exchanges andagency switchboards should be expected.
Though there were no other natural or manmade interruptions to telephone communications during the TMI response, such problems
are encountered frequently enough that an
104 3

i ndependent backup channel for critical communications would be prudent.
Radio communications between some locations were inhibited by terrain or intervening
structures.

11.

During the first few days of the response, thedivergent descriptions provided by different
organizations reflected a variety of interpretations of the same information. This is to be
expected in an accident situation. In order tominimize the problem, it is essential to ensurethat all evaluations are based on consistentand, to the extent possible, accurate information.
Communications between PEMA and BRP
were incomplete and, therefore, ineffective.
The flow of official information from the Stateto the counties regarding plant status and radiological matters was virtually nonexistent.
This presented a major problem to the county
and to local jurisdictions.
The need for rapid and accurate transmittal ofessentially identical information to several recipients was not satisfactorily met. There
were too many independent sequential
transmissions and there were too many intermediaries.
The rumor control center was established by
the State after the period of greatest need
was over.

The recommendations of this section are the following:

1. PEMA must carefully evaluate communications
systems to determine if the preassigned authorities and responsibilities of the various Federal,
State, and local agencies and the utility can be
carried out effectively during an emergency situation. This evaluation should include at least thefollowing:a. The assumption that switchboards and local exchanges will sometimes be overloaded by public and media calls.
b. Assuming overloaded telephone lines, simul ation of necessary communications traffic
among the utility, utility support organizations (such as the vendor and architectengineer), the NRC, other Federal agencies,
the Governor's office, various State agencies, the counties, local agencies and elected officials, and other States.

c. Experimental determination of adequatetransmission from predesignated command
posts, monitoring stations, and control
points when radio communications are to
be used.
d. Consideration of planned primary and alternate locations of the various command
posts involved in the emergency response.
e. Consideration of techniques that would permit simultaneous transmittal of information
to many recipients, information such as radiological assessments, plant status, etc.
f. Consideration of any backup equipment
needed for critical communications channels.
g. Rapid establishment of rumor control telephones.
h. Encouragement to State radiological healthorganizations to maximize staff involvementwith other governmental agencies, especially within the State, both before and during an emergency. Such involvement is
critical to the effective communication of
the actual and potential radiological hazards
and recommended appropriate protective
actions. Plans must be in place to draw
upon sufficient Federal agency support toaugment the essential field and laboratory
radiological measurements that this State
staff would normally perform, freeing someof this staff to perform the critical communications function.
i. The education of persons apt to be involved in response to an accident (including
plant control room personnel and auxiliary
operators) regarding the type of informationneeded during an incident (e.g., off-normal
critical parameters, radiological release
pathways, etc.) so that management personnel and response teams can better perform their functions. In relaying technicaldata, the source, units, date, and time forwhich the data are valid need to betransmitted. Standard data recording forms
should be used. Also, in responding to requests for information, emergency personnel must keep in mind that the person maki ng the request may not have a firm understanding of what is needed, and should
ask questions in order to clarify the request.
j. The State must take steps to assure thatnearby States are promptly informed of andthen kept up to date on the accident.
k. Where dedicated telephone lines arenecessary, they should preferably be fully
1044

operational, if they can also be useful innormal operations all the time, or theyshould at least be fully installed. Standby
i nstructions to the various telephone companies to ensure very prompt hookup in theevent of need should be readily available.
I. Where radio networks are necessary, theequipment should be routinely tested for
operability, and suitable arrangements must
be made for any necessary patching.
Where such systems would be borrowed
from other agencies (a good cost-effective
solution), suitable planning and testing mustbe performed to assure their availability ona timely basis, their operability, and their effective integration into the overall communications network.

2. Necessary information regarding the status of theemergency must be transmitted routinely andconsistently by all parties to all appropriate
Federal, State, county, and local government
agencies. The State must not rely exclusively on
the media to pass information to county and local
jurisdictions and to the public. The State must
make use of its existing institutional channels as
efficiently as possible so that local officials, who
get many questions from the public, will have thel atest official information available.
9. TECHNICAL SUPPORT FOR THE PLANT
a. Agency Response

I n addition to the many emergency response efforts aimed at protecting the public, the government
agencies made significant efforts in support oftechnical activities at the Three Mile Island plant.
These efforts were undertaken either in response todirect requests from the utility or in response to requests from the NRC. On March 30 the WhiteHouse designated the FDAA's Robert Adamcik toserve as lead Federal official for TMI with responsibility to coordinate the technical support tasks performed by Federal agencies other than the NRC.
The Department of Energy, through its Pittsburgh
Naval Reactors Office, made the initial agency efforts (aside from the NRC's) in support of the TMI-2
plant. In response to an NRC request, DOE's Bettis
Laboratory, near Pittsburgh, undertook a detailed
determination of the radioisotopic composition of ahighly radioactive primary coolant sample that was
obtained from the plant on March 29. In addition,
samples of the containment building atmosphereand of the contents of the TMI-2 waste gas storage

tanks were analyzed at Bettis during the first weekof the emergency response. Bettis later performed
a less elaborate analysis of primary coolant activity
from a sample taken on April 10. The primarycoolant analysis effort was also extended on April
10, and involved three other DOE Laboratories: Oak
Ridge National Laboratory in Tennessee, SavannahRiver Laboratory in South Carolina, and Idaho National Engineering Laboratory (INEL).
The Department of Defense provided air transport of the highly radioactive samples, which could
not be shipped on commercial aircraft, and billed thecosts to the utility. This same billing arrangement
was used for the large items discussed in theremainder of this section and for the large minesafety filters obtained from the Washington PublicPower System and transported from Pasco, Wash.,to Harrisburg, Pa. State agencies including the Air
National Guard and the State Police expedited thetransfer and delivery of materiel to the site.
Beginning on March 30 the escalation of concerns and the consequent expansion of contingency
preparation encompassed a number of plant-related
activities. Lead bricks, required for shielding a
recombiner being installed outside the containment,
were needed. The recombiner was to be used tomix, in a controlled manner, the hydrogen in thecontainment atmosphere with oxygen. Thus morethan 85 tons of lead were obtained during theweekend from Brookhaven National Laboratory, the
GSA stockpile, the National Bureau of Standards,
the DOE Pittsburgh Naval Reactors Office, and theArmed Forces Radiobiology Institute. Delivery to
the TMI site was completed on Sunday, April 1.
Concern over the hydrogen bubble spawned agreat many analytic, experimental, and consultative
support activities. NRC safety research programs inprogress at DOE laboratories such as INEL, and the
Sandia Laboratory in Albuquerque and the Los
Alamos Scientific Laboratory in New Mexico, were
diverted to support these activities. Other DOE
capabilities such as Bettis Laboratory and Knolls
Atomic Power Laboratory, near Schenectady, N.Y.,
made their experience and expertise available to the
NRC.
NASA sent W. A. Riehl from the Marshall Space
Flight Center to TMI to advise the utility on hydrogentechnology. The National Bureau of Standards provided technical data. The NRC independently solicited the advice of a number of university and industry experts.
On March 30 the NRC requested remote manipulation capability at the plant. The initial response
was from Oak Ridge National Laboratory. Their
mobile manipulator, nicknamed "Herman," arrived at
TMI on March 31 with its operating crew. Operating
104 5

procedures for use of the manipulator in obtaining
primary coolant samples were developed and tested. A second manipulator, owned by MBA Associates, a private concern, arrived at the site from Eglin
Air Force Base in Florida on April 1. Like many contingency preparations, these devices were neveractually used.
Waste management and decontamination efforts
started early and developed into a major long term
Oak Ridge and INEL supplied both
effort.
knowledge and onsite manpower in support of therecovery effort. A number of other DOE laboratories, including Argonne, Sandia, and SavannahRiver, provided laboratory services. The Departmentof Transportation later contributed to this activity by
assisting in locating potentially available railroadtank cars and then putting the utility in contact withthe owners.
The problem of conducting operations at a contaminated plant, particularly in a contaminatedatmosphere, was a continuing concern. SavannahRiver provided the plant with supplementary
supplied-air respiratory equipment, including 140
plastic suit jackets with air distribution systems.
The Hanford Engineering Development Laboratory,in Richland, Wash., provided two breathing-air distribution manifolds. The Mine Safety and HealthAdministration of the Department of Labor supplied
18 Draeger oxygen breathing systems as well as astaff to train personnel in using them.
A miscellany of other support activities were carried out by various DOE laboratory groups. For example, Oak Ridge performed noise measurements
and analysis to detect coolant boiling; Argonne performed analyses related to fuel damage; Sandia
prepared a preliminary design of a containment
vent-filter system that might be used in the event ofa core meltdown; and Oak Ridge provided instrumentation expertise, which was used to evaluate thereliability of existing instruments and to modify andi mprove instruments 'that were accessible and inneed of modification.
b. Findings and Recommendations
The cooperation of the Federal agencies in
responding to the needs expressed by the utility or
the NRC in preparing to deal with a variety of possible recovery scenarios, and their success in meeti ng these needs, was commendable. The effort was
mounted and executed on an ad hoc basis, andwas, therefore, somewhat less efficiently executed
than would have been possible if the effort had beenvery carefully preplanned. Since such preparation
for a wide spectrum of possible accidents would bevery expensive, we have not been able to conclude
that the benefits of such specific preplanning would
outweigh the costs.
There are no recommendations.

9.

Bibliography
1.

This section is based on the following sources:

2.

3.

4.

5.

6.

7.

8.

10.

Memorandum from H. G. Rickover, DOE Division of Naval Reactors to Robert Ferguson,
DOE Office of Nuclear Energy Programs, Subject: Assistance Provided by DOE Division of
Naval Reactors, Pittsburgh Naval Reactors
Office, Schenectady Naval Reactors Office,Bettis Atomic Power Laboratory and theKnolls Atomic Power Laboratory, dated May
24, 1979.
Memorandum from Joseph A. Lenhard, DOE
Oak Ridge Operations Office, to Robert Ferguson, DOE Office of Nuclear Energy Programs, Subject: Assistance provided by Oak
Ridge Operations and Oak Ridge National
Laboratory, dated 5/25/79.
Memoranda from N. Stetson, DOE SavannahRiver Operations, to Robert Ferguson, DOE
Office of Nuclear Energy Programs, Subject:
Assistance provided by Savannah River
Laboratory and Savannah River Plant of E. I.
duPont de Nemours and Company, dated
5/25/79 and 4/25/79.
Memorandum from Charles E. Williams, DOE
I daho Operations Office, to Robert Ferguson,
DOE Office of Nuclear Energy Programs, Subject:
I nformation
RequestedbythePresident's Commission on Three Mile Island,
dated 5/29/79.
Memorandum from Gil E. Cordova, DOE Albuquerque Operations, Sandia Area Office, toRobert Ferguson, DOE Office of Nuclear
Energy Programs, Subject: Three Mile Island
Accident, dated 5/22/79.
Memorandum from Robert H. Bauer, DOE Chicago Operations, to Robert Ferguson, DOE
Office of Nuclear Energy Programs, Subject:
Information Requested by the President's
Commission on Three Mile Island, dated
6/6/79.
Memorandum from F. R. Standerfer, DOE
Richland Operations Office, to R. L. Ferguson,
DOE Office of Nuclear Energy Programs, Subj ect:
I nformation
RequestedbythePresident's Commission on Three Mile Island,
dated 5/25/79.
List of titles of TMI-related activities at Los
Alamos Scientific Laboratory (LASL) and San-11.

dia supplied by DOE Albuquerque Operations
Office.
Memorandum for the President from Jack
Watson, Subject: "Federal Contingency Plans,
Three Mile Nuclear Facility," dated March 30,
1979.
Note to Mr. Schivinghamer from W. A. Riehl,
Subject: "Technical Support to Three Mile
Island Nuclear Power Plant Incident," dated
April 5, 1979.
Letter to E. K. Cornell from James P. Wade,
Jr., Assistant to the Secretary of Defense(Atomic Energy), October 10, 1979.

10. SUMMARY OF FINDINGS AND
RECOMMENDATIONS
A summary of our findings and recommendations
regarding the response of Federal (except the NRC)
and State agencies to the TMI accident is provided
below. These findings identify a number of specifici nadequacies regarding the emergency planning andresponse of the various agencies. The reader iscautioned to refer to the preceding sections for detailed findings regarding inadequacies of response
and for detailed recommendations of corrective actions. A reasonable understanding of the importance and scope of many of the general findingssummarized below cannot be fully achieved withoutfamiliarity with the supporting detail.
a. Root Cause
Finding

The principal finding is that the root cause of
most of the inadequacies in governmental emergency response, and a contributory cause of all of theinadequacies, was the NRC's failure to promote anawareness that nuclear powerplant accidents with
substantial offsite consequences are possible andmust be planned for. The NRC did not sufficiently
emphasize emergency planning, nor did the NRC require an adequate State emergency plan as a condition for operation of a reactor. On Friday, March
30, the NRC recommended that evacuation beplanned for areas within 10 and 20 miles of theplant; before March 28 they suggested State andl ocal planning only for evacuation of the applicablel ow population zone, a distance of only 2 miles for
the TMI reactors.
We believe that the NRC's use of the word credible in describing the classes of accidents used in
the design basis (and its implication thereby that1046

other accidents are "incredible") contributed significantly to the general attitude that serious emergency planning was not important. The attitude has
been reinforced in two ways:

1. The NRC has judged the so-called Class 9 accidents (accidents with consequences greaterthan the design basis accidents) to have a likelihood of occurrence so low that no specific consideration of these accidents is required in thedesign review process. If the NRC did consider
these Class 9 accidents in planning emergency
response, it would probably be criticized for planning for them while neither requiring reactors tobe designed to preclude their occurrence nor requiring reactors to be sited in such a manner as
to reduce offsite consequences should such an
unlikely accident happen. The result is that, while
the NRC clearly acknowledges the remote possibility of Class 9 accidents, it so effectively downplays such accidents that no emergency
response planning for them takes place.
2. The NRC evaluates credible accidents in a conservative manner. The analysis is based on almost "worst case" assumptions of plant failure,release of radioactive materials, and possible exposure to persons off site. Because of this conservative analysis, the NRC's attitude has become one of not really believing that even theso-called "credible" accident will have much likelihood of occurring, or at least not with offsite
consequences as great as calculated. This tends
to downgrade the importance that the NRC (andthrough the NRC, the State and the public) placeson emergency planning, even for low population
zones.
Recommendation

The NRC must adopt a policy that requires reasonable offsite emergency planning, and such planning must consider emergency response to low
probability accidents having offsite consequences
greater than those analyzed as credible in thedesign review. This policy is an important aspect of
the NRC's defense-in-depth concept, which
deserves strong reemphasis.
b. SitingFinding

Characteristics of an area, such as population
density, road networks, and the existence of nearby
prisons or large hospitals can substantially influence
the effectiveness of evacuation.

Recommendation

The NRC must establish the areas for which
evacuation planning is required and the maximum
ti mes within which evacuation of the areas must be
conducted. To the extent possible, these criteria
should establish siting limits based on demographic
and other characteristics that substantially influence
the effectiveness of evacuation. However, such criteria must have a reasonable basis. Unnecessarily
restrictive criteria could result in a substantial loss insiting options for a nuclear powerplant without acommensurate improvement in the effectiveness of
emergency response. A substantial loss in siting
options would unreasonably limit consideration ofother important safety and environmental siting
characteristics such as water availability and use,land use, seismicity, flooding, ecological impacts,
community impacts, and aesthetics.
c. Overall I nstitutional Coordination
Finding

Federal and State officials generally understoodand implemented their respective legal authorities
and responsibilities; for example, DOE's initial radiological response was in accordance with its prioragreements with the NRC and the Commonwealth ofPennsylvania. However, the Federal response effort
beginning on Friday was not coordinated, principally
because neither FRPPNE nor IRAP provides an adequate response plan. Although FRPPNE provides al engthy treatise on Federal authorities and responsibilities, and IRAP provides a resource inventory anda reasonable basis for interagency coordination ofradiological monitoring and assessment functions,
neither of them establishes a clear plan for overall
effective Federal coordination and response. This
resulted in some confusion on Friday and made itnecessary for the White House to intervene and to
take strong actions to assure Federal coordination.
While this inadequate coordination had little effecton the TMI response, it is possible that under similar
circumstances the response to a fast-moving accident would have been unnecessarily impaired.
At the State level, it is not clear how PEMA would
have discharged its command function as requiredby State law had a prompt emergency evacuation
been required. Emergency command and control
duties and procedures had not been clearly established for PEMA, and the statutory command function appears to fly in the face of the established autonomy of the local and county jurisdictions. However, it is likely that PEMA would not have attempted to assert control but would have discharged its

104 7

characteristic coordination role. Thus, a confrontation of command (with its accompanying confusionand possible loss of efficiency) would have been unli kely.
Recommendation

Clear and explicit Federal and State emergency
response coordination and command roles must be
established and understood by all parties. The
basic i nstitutional framework for emergency
response provided in formal, understandable plans
must contain the following:

1. The utility licensee must be fully responsible forthe safe operation of the reactor and appropriate
emergency response, and should make recommendations for protective action guides to offsite
Federal and State authorities.
2. The NRC must be responsible for all regulatory
activities concerning the safe operation of theplant, independent assessments of plant status
and operations, and recommendations regarding
protective actions that might be warranted toThis latter
reduce radiological exposures.
responsibility is also shared to some extent by
EPA and HEW and thus must be well coordinated.
3. FEMA must be responsible for ascertaining that
adequate Federal, State, and local emergency
plans exist and are properly maintained and tested, assuring that NRC concurrence is received
on those portions of the plans that are unique tothe hazards and emergency response actions
peculiar to nuclear reactors. Further, FEMA
should provide appropriate coordinated Federal
response to State and local agencies following
reactor accidents that have a potential for substantial offsite radiological consequences. However, regarding the adequacy of State and local
emergency plans, FEMA must make optimal useof the work that the NRC has done and ispresently doing in the areas of providing guidance and reviewing existing plans.
4. DOE is basically responsible for providing radiological monitoring support to the State. Under
IRAP, other Federal agencies might share inthese responsibilities, but such responsibilities asinteragency coordination and the triggering
mechanism for IRAP need to be better defined.
5. EPA should be responsible for long term radiol ogical monitoring and assessments after an accident, and HEW should be responsible for assessing the health effects on persons in the area.
6. Local and county jurisdictions should retain basic
responsibility for the immediate protection of thehealth and safety of their citizens.

7. State governments should retain responsibility forthe overall health and safety of citizens and forproviding effective and coordinated assistance tolocal and county jurisdictions in any emergency
situation.
d. Overall Emergency Planning
Finding

Effective emergency response begins with adequate operational plans at the local level and requires the development of integrated, functional, andtestable emergency plans at the county, State, andFederal levels. The plans should further be suitably
meshed with the utility's emergency plan. At theti me of the TMI accident:

1. No local plans existed, although local authorities
appeared to be reasonably familiar with theresources available to them to implement protective actions.
2. County plans appeared to be reasonably adequate for a 5-mile evacuation, but no plans forevacuations out to 10 or 20 miles existed.
3. Because of the added complexities of larger populations, more extensive road networks, and thei nclusion of hospitals and a prison in the 20-milearea around TMI, the development of an effective
evacuation plan out to that distance required
much more detail and much better coordination
among the various local and county jurisdictions
than was required for effective 5-mile plans.
While it was subsequently determined that a 20mile evacuation was not needed, the State continued 20-mile planning because spontaneous
evacuation out to 20 miles was likely to occur inthe wake of a 10-mile evacuation order.
4. The State emergency plan appeared adequate tosupport the rapid evacuation of a 5-mile area.
5. The DOE had an effective radiological responseplan, which, however, lacked suitable criteria totrigger its response. The plan required a requestfrom another agency, and, at TMI, this request
was not timely.
Recommendation

Appropriate emergency plans, suitably meshedwith the utility's plan, must be developed and routinely tested at all levels of government. These
plans must include sufficient detail to facilitate a reasonably prompt and effective 10-mile evacuation.
The utility should in some manner provide the fundi ng appropriate for the development and testing of

104 8

local emergency plans. While NRC rules should require the existence of a federally approved Stateplan prior to licensing, they should not require theexistence of a federally approved local plan. The
State plan, however, must require the preparation ofl ocal plans, and the utility, in addition to providing
funding for local planning, must be required to conduct effective training sessions in local jurisdictions
and must cooperate in comprehensive testing of theplans, though not to include actual evacuations.
e. Evacuation
Finding

We find that existing local plans likely would havebeen adequate to conduct a 5-mile evacuation inabout 6 hours, and that the detailed planning during
the weekend of March 30 to April 1 likely would
have permitted a 10-mile controlled evacuation inabout 10 hours. (A controlled evacuation is one inwhich emergency response resources, such as
buses and traffic-control police, are assembled prior
to the public notification to evacuate.) We also findthat precautionary evacuation advisories for selected members of the population cannot be issued
after a nuclear powerplant accident without anticipating that substantially greater numbers of people
will evacuate. The recommendation that pregnant
women and preschool-age children within 5 miles of
TMI evacuate led to the voluntary evacuation of 20
ti mes that number of people from a region extendingout to 15 miles from the plant. Because of the lowlevels of radioactivity experienced and anticipated,
and the large numbers of volunteer evacuations, we
believe that the appropriateness of the selective
evacuation of pregnant women and children is questionable. It is likely that the uncertainty of information regarding plant status played the major role inthis decision. In spite of this, we found little to fault
the Governor's decision, considering the events ofMarch 30. Also, we commend the Governor for his
insistence on establishing a meaningful verification
process for recommendations concerning various
protective actions.
Recommendation

Evacuation plans must be prepared based on the
expectancy that the evacuation of selected persons
will result in the voluntary evacuation of many more
people than specified, and that many -people living atleast twice as far as specified from the reactor will
also evacuate. The evacuation plans must establish
channels through which recommendations should

104 9

flow to the decisionmaker and must establish
processes for the verification of substantial information and all recommendations.
Criteria for recommending evacuations and otherprotective actions must be clearly established andmust take into consideration the role that will beplayed by the uncertainty of information regarding
plant status.
The benefits and costs of all protective actions
must be evaluated in the establishment of these criteria, and these benefits and costs must be clearly
articulated to enhance public understanding as tothe actual hazards of radiation and the purpose andappropriateness of various protective actions. Also,
the results of other evacuations (such as at Mississauga) should be studied to identify the degree ofplanning useful for an effective evacuation and to
identify those characteristics that greatly impair theeffectiveness of evacuation, i.e., that might prohibit
an effective evacuation or greatly increase the timerequired to conduct such an evacuation.
f. Other Protective Actions
Finding

During the TMI accident, protective actions otherthan evacuation were either taken or considered,though the actual and expected levels of radioactivity in the environment ranged from as little as .5% to
10% of published protective action guides or radiological discharge limits. Such actions included: (1)prohibiting the plant from discharging wastewater on
Thursday afternoon and night, (2) closing meatpacki ng plants on Friday, (3) putting cows on stored feed
and water, (4) recommending the distribution anduse of potassium iodide, and (5) issuing a takeshelter advisory on Friday morning.
The advisability of such protective actions is constantly in the forefront of officials' thoughts and isassessed and reassessed in light of changing information. The first three actions listed above were
not warranted by the facts of the accident at TMI; allfive are subject to question as to their appropriateness. Unlike evacuation, the above actions should
be seriously considered only if anticipated radiation
l evels or doses approach published radiation limits
or protective action guides. This is so becausesuch limits and guides are conservatively set, andthese actions can be quickly and usefully implemented, even after a release in many cases. Uncertainty concerning the forecasts of radiological exposure should play a minor role in decisions to implement such protective actions, though uncertainty
l egitimately plays a major role in decisions toevacuate.

DOE should be the lead agency with regard to
the collection and assessment of radiological monitoring data in any multiagency emergency response.
Also, appropriate radiation monitoring equipment
must be readily available to every nuclear plant, andarrangements must be made for training of emergency personnel in its use.

We find that some inadequacies in managing theprotective actions listed above stemmed from confusion caused by inadequate information and by attempts to manage the response from Washington.
Also, potassium iodide for use as a thyroid blocking
agent was not readily available in the United States,
i n large part because the NRC had not promulgatedrequirements for stockpiling it.

h. Physical Communications

Recommendation

The NRC, in cooperation with HEW and the EPA,
must establish mutually agreeable, uniform protective action guides. It must clearly define the purpose of these guides and must prescribe criteria for
their application in decisions regarding various protective actions. Such criteria must set forth thecosts and benefits of each protective action so thata decisionmaker has full knowledge of all aspects ofprotective actions and their alternatives before hemakes a decision. Promulgation of such guides
would also help stem the NRC's demonstrated inclination to manage the emergency response decisions from Washington.
The NRC must also develop criteria for the
storage and distribution of potassium iodide so thatit can be reasonably available to the public ifneeded.

Finding

Commercial telephone systems are not satisfactory for communicating detailed technical information during an emergency. In times of a serious
emergency it must be expected that the public
response will quickly overload existing telephoneexchanges, effectively prohibiting use of the commercial system even for nontechnical emergency instructions and information. A system of dedicatedtelephone lines must therefore be in place before an
accident occurs.
Recommendation

FEMA must carefully evaluate communications
li nking all participants in emergency response systems to assure that the systems are adequate for
emergency communications. Such an evaluation
should consider the availability of backup systems
as appropriate, communications from alternate command posts, and the use of automated datatransmission.

g. Radiological Monitoring Efforts
Finding

The radiological response to the releases experienced during the TMI accident was more than adequate and would have been adequate for muchlarger releases. However, there was some unnecessary delay on Wednesday in requesting DOE
aid when the high radiation levels measured in thecontainment building should have triggered such arequest. In addition, there was some confusion
about the responsibility for coordinating radiological
data and assessments on Friday. And, there were
too few personnel monitoring devices of appropriate
range, a situation which could have affected theemergency response actions of the State Police andthe National Guard had radiological releases necessitated an evacuation.

i. The Act of Communicating
Finding

A major contributor to concerns and fears of officials and the public was the absence of adequate,
accurate, and confirmatory information. To someextent this failure of information is unavoidable, but
the failure at TMI could have been mitigated by abetter choice of information to be communicated,
the use of better informed and more knowledgeable
communicators, and by increased attention to theoverall problem of effective human communications
about a complex subject in the face of an
emergency.

Recommendation

A DOE Radiological Assistance Team must be
automatically dispatched whenever there is a clearly
abnormal radiological situation at a nuclear powerplant; formal procedures to this effect must be
i nstituted.

Recommendation

All organizations involved in emergency responsemust assess their information needs to assure theeffective and timely communication of all necessary
1 05 0i nformation during an emergency. This assessment
must not only include evaluation of the informationneeds of each organization and the manner in which
the information will be communicated to them, but it
must also include a policy regarding the flow of information to the media and in response to public
i nquiry.
j. Comparison with the Conclusions of the
President's Commission
We are in general agreement with the findings
and recommendations of the President's Commission in the areas discussed in this section. We find,however, that for some of the topics, the findings ofthe Kemeny Commission are incomplete and are,therefore, susceptible to misinterpretation. Some
examples which illustrate this observation are given
below.
1. On page 16 of the Kemeny Report the text implies that there could have been an extremely
dangerous situation at TMI because of the lack of
local emergency plans. We have found that, ingeneral, county and local jurisdictions understood

105 1

the resources available to them well enough tohave conducted a successful 5-mile evacuationeven in the absence of detailed, formal plans.
However, because of the added complexities of
evacuating areas 10 or 20 miles around TMI, we
believe the more formal plans would substantiallyhave reduced the time required to conduct a
controlled evacuation of the larger areas.
2. On page 37 of the Kemeny Report the Commission finds that the State public health officials andhealth care providers in the TMI area "did nothave sufficient resources to respond to the potentially serious health consequences of the ac-

TH."

We beAieve that this finding isliterally correct, but should not serve as a basis
for concluding that major new State capabilities
are required. Because of the substantial personnel and equipment resources required to respondto a radiological emergency with potentially serious health consequences, we believe it inappropriate and uneconomical for State agencies tomaintain sufficient resources to respond effectively to such unlikely accidents. Such resourcesmust be made available to the States from appropriate Federal agencies, however, on a preplanned, expedited basis.
cident at

REFERENCES AND NOTES'Details of the plant status chronology and operator
actions are presented in Section II.A. of this report.
2
The Emergency Plan for Three Mile Island defines
three different action levels for emergencies.
a. A Local Emergency exists upon the discovery of
any condition(s) which could affect the safety of
personnel or equipment and involves only areas
within a unit.
b. A Unit Emergency (Site Emergency) exists on
occurrence of a major accident which could potentially result in the release of radioactive material tothe immediate environment.
c. A General Emergency is an incident which involves
areas external to the station boundary.
3
The Joint Nuclear Accident Coordinating Center,
staffed jointly by the Department of Energy (DOE) and theDepartment of Defense (DoD), serves as the clearinghouse for information relating to response to emergencies
i nvolving radioactive materials under the jurisdiction of the
DOE and DoD.
4The Office of Congressional Affairs, in the NRC,
called the majority and minority staffs of the House Committee on Energy and Environment, and the Senate Subcommittee on Nuclear Regulation, as well as Senators
Schweiker and Heinz and Representatives Walker and
Ertel, all of Pennsylvania.
STranscription, Press Conference, Lieutenant Governor William W. Scranton, 3rd, Incident at Three MileI sland, March 28,1979. Identification number 321-D79.
6
Transcription, Press Conference, Lieutenant Governor William W. Scranton, 3rd, Incident at Three Mile
Island, March 28, 1979, 4:30 p.m., Identification number
322-D.
7
The Federal agencies participating in the Friday
meeting were the Nuclear Regulatory Commission (NRC),
the Defense Civil Preparedness Agency (DCPA), theFederal Disaster Assistance Administration (FDAA), theFederal Preparedness Agency (FPA), the Department ofEnergy (DOE), and the Department of Defense (DoD).
8
PEMA had officially lifted the take-cover advisory atnoon on Friday. It is unclear why this mix-up occurred.
9
Memorandum from Jack Watson to multiple addressees, subject: "Coordination of Federal Response toThree Mile Island and Designation of Thomas C. Maloneyas Lead Federal Official," The White House, April 19,
1979.
10
On July 15, 1979, the Federal Emergency Management Agency (FEMA) assimilated the personnel and the
responsibilities that had previously been assigned to the
Defense Civil Preparedness Agency (DCPA), under the
Department of Defense; the Federal Preparedness
Agency (FPA), under the General Services Administration;and the Federal Disaster Assistance Administration(FDAA), under the Department of Housing and Urban
Development.
"Reorganization Plan No. 3 of 1978, approved by
Congress on September 16, 1978, established the Federal
Emergency Management Agency. In July 1979, theDefense Civil Preparedness Agency, the Federal Disaster
Assistance Administration, and the Federal Preparedness
Agency were placed under FEMA by Executive Order
12148.

Disaster Relief Act of 1974, Pub. L. No. 93-288, Sec.
102(b).
13
Id., Sec. 306(a).
14!d., Sec. 402.
15
14., Sec. 305(c).
16Federal Response Plan for Peacetime Nuclear Emergencies (Interim Guidance) Annex II, "An Analysis of Legal
Authorities in Support of the Federal Response Plan for
Peacetime Nuclear Emergencies," dated April 1977, at 8.
17
Federal Response Plan for Peacetime Nuclear Emergencies(Interim Guidance) at 4, dated April 1977.
18
Adamcik
Interview Transcript at 8-9.
19
Pres. Com. Hearing (Aug. 21,1979) at 13-14.
20
Memorandum from Jack Watson, White House Staff,
to J. Califano, HEW; J. Schlesinger, DOE; D. Costle, EPA;"Long Term Environmental Radiation Monitoring at Three
Mile Island," April 13, 1979.
'*'Commonwealth of Pennsylvania Disaster Operations
Plan, Annex E, "Nuclear Incidents (Fixed Facility)," dated
July2212, 1977, at 1.
Cover letter by M. J. Shapp, Governor, for the Commonwealth of Pennsylvania Disaster Operations Plan,
dated July 12,1977.
23Pen n. Consol. Stat., Tit. 35 (1978).
241d., Chap. 73, Sec. 7301(a).
25Section 7301(d) of the Pennsylvania Consolidated
Statutes Title 35 (1978) provides that: "Activation ofdisaster response. - An executive order or proclamationof a state of disaster emergency shall activate the disaster response and recovery aspects of the Commonwealthand local disaster emergency plans applicable to the political subdivision or area in question and shall be authority
for the deployment and use of any forces to which theplan or plans apply and for use or distribution of any supplies, equipment and materials and facilities assembled,stockpiled or arranged to be made available pursuant tothis part or any other provision of law relating to disasteremergencies."
26
Penn. Consol. Stat., Tit. 35, Chap. 73, Sec. 7313(7)(1978).
27
Penn. Consol. Stat., Tit. 35, Chap. 75, Sec. 7501(b)(1978).
28
Henderson dep. at 18-19.
29
Id. at 20.
30
Protective action guides are discussed in Sections
III. C.4
and 6.
3'Pres. Com. Hearing (August 21,1979) at 64.
32
Letter from T. M. Gerusky, Director of Bureau of
Radiation Protection, to B. T. Lunden, PC Staff Director,
Subject: Activities During Three Mile Island Accident,
dated June 18,1979.
33Pennsylvania Emergency Management Agency Log,
Message 29, time 0752, dated March 28,1979.
34Pennsylvania Emergency Management Agency Log,
Message 44, time 0818, dated March 28,1979.
35Letter from T. M. Gerusky, Director of Bureau of
Radiation Protection, to B. T. Lunden, PC Staff Director,
Subject: Activities During Three Mile Island Accident,
dated June 18,1979.
12

105 2

Transcript of IRC Tape, Number 02-212-CH6-CLB4
through 6, dated March 29,1979.
37
Pres. Com. Hearing (August 2,1979) at 136.
38
14. at 140-141.
39
14. at 137-140.
40
Robbins dep. at 36-37 (Pres. Com).
41
Pres. Com. Hearing (August 2,1979) at 139-140.
42
14. at 143-145.
Floyd dep. at 226 (Pres. Com).
44
Kuehn dep. at 20.
45
Pennsylvania Emergency Management Agency Log
Message 14, time 0840, dated March 30,1979.
48
Pres. Com. Hearing (August 2,1979) at 94.
47
Lamison dep. at 40.
48
Pres. Com. Hearing (August 2,1979) at 41-42.
49
14. at 96.
38

14. at 10.
14. at 44.

50
51

52

Molloy dep. at 46.
NRC Commission Meeting Transcripts (March 30,1979) at 73-78.
"Memorandum of Telephone Conversation with Martha Lester, WHP, from F. Herr, NRC/SIG Task Group 6,
to M. Emst, Task Group Leader, "Governor's Stay
I ndoors Advisory," November 8,1979.
55
Report of the Office of Chief Counsel on Emergency
Response to the President's Commission on the Accident
at Three Mile Island, dated October 31,1979, at 55.
58
Transcript of Governors Press Conference dated
March 30, 1979, time 12:30 p.m., at 4.
57
Transcript of Governor's Press Conference, dated
March 30,1979, time 10:00 p.m., at 1.
58
Pennsylvania Emergency Management Agency Log,
Message 42, time 1240, dated March 30,1979.
59
Transcript of Governor's Press Conference, dated
March 30,1979, time 12:30 p.m., at 1.
60
Hearing Before the Subcommittee on Nuclear Regulation of the Committee on Environmental and Public
Works, 96th Congress, 1st Sess. 240 (April 23,1979).
53

81

Transcript of Governor's Press Conference, dated
March 30,1979, time 12:30 p.m., at 1.
2
e 0ffice of the Governor Chronology, dated March 30,
1979.
83
NRC Commission Meeting Transcripts (March 30,1979) at 122-129.

"Transcript of Governor's Press Conference, dated
March 30,1979, time 12:30 p.m., at 1.
65

Transcript of White House Press Secretary's Press
Conference, dated March 30,1979, time 5:00 p.m.
88

Transcript of Governor's Press Conference, dated
March 30,1979, time 10:00 p.m., at 1.
"Transcript of NRC Chairman's Press Conference,
dated March 31,1979, time 2:45 p.m., at 14-15.

88
NRC Commission Meeting Transcripts (March 31,1979) Section 3, at 8.

Bs AP Press Release, time 8:23 p.m., dated March 31,

1979.

70

Transcript of Governor's Press Conference, dated
March 31,1979, time 11:00 p.m., at 1.

71

Molloy dep. at 55.
Molloy dep. at 16 (Pres. Com.).
73
Report of the Office of Chief Counsel on Emergency
Response to the President's Commission on the Accident
at Three Mile Island, dated October 31, 1979, at 126.
74
1J.S. Nuclear Regulatory Commission, "Population
Dose and Health Impact of the Accident at Three Mile
Island Nuclear Station," NUREG-0558, May 1979.
75
Three Mile Island Telephone Survey, NUREG/CR1093, October 1979.
76 York County Log of Events Pertaining to Three Mile
Island, dated March 30,1979, at 1.
77W. D. Lentz,
American Red Cross, "Mass Care
Report D.R.-014," April 10, 1979, at 1.
78
1d.at 179
Pennsylvania Emergency Management Agency Log,
Message 14, time 0520, dated March 31,1979.
72

Leslie Jackson, York County Emergency Preparedness Office, Supplement to SIG interview.
81
Prewitt Interview Memo at 5.
82
Governor's Press Release, dated April 9, 1979, at 1.
83
Pennsylvania Emergency Management Agency Log,
Message 639, time 1035, dated April 7,1979.
"Transcript of Governor's Press Conference, dated
April 9,1979, time 3:00 p.m., at 2.
85
Pres. Com. Hearing (August 21,1979) at 64.
86
Commonwealth of Pennsylvania Disaster Operations
Plan, Annex E, "Nuclear Incidents (Fixed Facility)," dated
July 12, 1977.
87
NRC Office of State Programs Meeting with
Pennsylvania State Officials on July 11, 1979, Transcript( Harrisburg, Pa.), at 39-40, dated July 27,1979.
88
Memorandum from W. H. Wilcox, FDAA, to J. Watson, Assistant to the President, "Report No. 4, Three Mile
Island Incident," at 2-3, April 2,1979.
89
Memorandum from W. H. Wilcox, FDAA, to J. Watson, Assistant to the President, "Report No. 5, Three Mile
Island Incident," at 3, April 3,1979.
90
Pres. Com. Hearing (August 2,1979) at 30.
91
Henderson dep. at 52.
92
Williamson dep. at 16,19.
93
Blosser Interview Memo at 3.
"Henderson dep. at 48-49.
95b.
at 50.
"Jackson Interview Memo at 4.
97
Crowe dep. at 11-14.
98
Wilburn dep. at 17.
99
Id. at 14-17.
100
Jackson Interview Memo at 4.
101
John McConnell Interview Memo at 4.
102
Henderson dep. at 81.
103
There are other drugs that can be effectively used
as blocking agents. Problems with these other drugs
such as toxicity, expense, or too little experience with thedrug led the NCRP to conclude that potassium iodide was
the best drug to use.
104
National Council on Radiation Protection Measurements, "Protection of the Thyroid Gland in the Event of
Releases of Radioiodine," NCRP Report No. 55 at 26,
paragraph 4.5.7, dated August 1, 1977.
80

105 3

The National Council on Radiation Protection andMeasurements is a nonprofit corporation chartered by theCongress in 1964 to collect, analyze, develop, anddisseminate information and recommendations about
radiation protection. The Council is made up of 56 scientific committees composed of experts having detailed
knowledge and competence in the particular area of thecommittee's interest.
105

106

National Council on Radiation Protection and Measurements, "Protection of the Thyroid Gland in the Event of
Releases of Radioiodine," NCRP Report No. 55, at 32,
dated August 1, 1977.
107
Id. at 33.
108
Department of Health, Education and Welfare, Foodand Drug Administration, "Potassium Iodide as a Thyroid
Blocking Agent During a Radiation Emergency," Federal
Register, Vol. 43, No. 242, dated December 15, 1978.

109
National Council on Radiation Protection and Measurements, "Protection of the Thyroid Gland in the Event of
Releases of Radioiodine," NCRP Report No. 55 at 23,
dated August 1, 1977.
110
Each 1-ounce bottle contained enough potassium
iodide for 45 people for 10 days.

"G. K. MacLeod, M.D., FACP, Secretary of Health,Commonwealth of Pennsylvania, "The Decision to Withhold Distribution of Potassium Iodide During the Three
Mile Island Event: Internal Working Document," at 5,undated.
1120. at 6.
"3 Id. at 16-19.
114
14. at 9,18.
115

Memorandum from J. A. Califano, Jr. to J. Watson,"Recommendations of the Surgeon General with Respect
to Thyroid Blocking," at 2, dated April 3, 1979.
118

G. K. MacLeod, M.D., FACP, Secretary of Health,Commonwealth of Pennsylvania, "The Decision to Withhold Distribution of Potassium Iodide During the Three
Mile Island Event: Internal Working Document," at 21,
undated.
n7/d. at 21-22.

The potassium iodide was returned to the FDA in
July 1979 and is now being stored by the Department of
Health, Education and Welfare at the National Center for
Toxicological Research in Jefferson, Ark.
118

"Department of Environmental Resources, Bureau ofRadiological Health, "Plan for Nuclear Power Generating
Station Incidents," September 1977.
120A picocurie is a very small unit (one trillionth of acurie) used to express the radioactivity of a material.
121
The protective action options available as preventive
measures to decisionmakers include removing cows frompastures and feeding them on stored feeds. If significant
levels of radioiodine have already been found in milk, two
options are available; the choice is made depending on
the level of contamination. At low levels the milk can bediverted from use as fresh fluid milk to use as processed
milk products, such as powdered milk and cheese, which
can be stored until the radioactivity decays to acceptablelevels. At higher levels, the milk would be condemnedand subsequently destroyed.
122

The process for detecting radioactive iodine in milk
i nvolves placing the sample under a counting device; the105 4l ength of time the sample is counted is a major determinant of the level of radioactive iodine detectable.
Detection and measurement of low levels of radioactivity
i n milk can also be accomplished by removing the waterfrom the milk in order to concentrate the radioactive portions. The minimum detectable levels established by various political jurisdictions during the TMI event were generally in the 20- to 30-pCi/I range because it was
believed the benefits to be derived from establishing
lower detection levels did not justify the costs involved inlonger counting times or processing.
123
The Pennsylvania Department of Agriculture had
located alternate feed supplies in the event farms ran out
of feed or feed supplies in the TMI area became contami nated.
124
The Maryland Department of Health and Hygiene
processed several samples of milk and counted them for
1,000 minutes, lowering the minimum detectable level to.3 pCi/I. No radioiodine was detected in these samples_
125

Transcript of Press Statement by the Secretary of
the Department of Environmental Resources (theGovernor's Press Office, 318R) dated March 29,1979.
126
DOE's RAP teams are experienced and equipped torespond to requests for radiological assistance. For theperiod of July 1958 through December 1978, DOE (andbefore the DOE, the AEC) sent out RAP team members
on 683 occasions. On 259 of these, a single individual
was sent and, on 424, a team responded. Teams arecomposed of health physicists and technicians from DOE
contractor facilities and may be accompanied by a DOE
employee. Figure 111-15 shows DOE's radiological assistance experience for 1958-1978.

127 For example, about 2 weeks after the accident, theWhite House charged the EPA with full responsibility forlong term radiological monitoring.
128

Brookhaven Area Office Communications Log,
Appendix B, "DOE Region I Radiological Assistance Program (RAP) Response to the Incident at Three Mile Island:
March 28-April 18,1979," at 2.
129

Eidenberg dep. at

147-153.

13 °Three Mile Island Station, Radiological Emergency
Procedure 1670.2, Figure 4, Revision 9, November 22,
1978.
131 J. L. Tew, "Technical Staff Analysis Report toPresident's Commission on the Accident at Three MileI sland on the Catalog of Events," at 31 and 46, October
1979.
132
York County Log of Events Pertaining to Three MileI sland, dated March 28,1979, at 1.
133
NRC's Office of State Programs Meeting with
Pennsylvania State Officials on July 11, 1979, Transcript(Harrisburg, Pa.), at 10.
134

Id. at 19.
Deddens dep. at
1wBaunack dep. at
135
137

37, 41.

22.

Letter from D. J. Culkin, AT&T, to Dr. Larry F.
Darby, FCC, Subject: Report on Telephone Industry's
Response to the TMI Accident, at 3, dated April 27,1979.
138
Pennsylvania Emergency Management Agency
Action Log, Message 21, time 0922, dated March 28,
1979.
139
Watson dep. at 13 (Pres. Com.).

*INCLUDES REQUEST FOR INFORMATION ON RADIATIONHAZARDS REPORTED AS ASSISTANCE REQUESTS.

FIGURE 111-15. DOE Radiological Assistance Incident Experience,
July 1958-December 1978

14

"Report of the Public's Right to Information Task
Force to the President's Commission on the Accident atThree Mile Island," dated October 31, 1979.
141
Memorandum from L. P. Crocker, NRC, to M. L.
Ernst, "White House Communications Agency," November
19, 1421979.
Deal Interview Memo at 2 and 4.
14
sKuehndep. at 4-5.
144
Henderson dep. at 43.
140

sAdamcik Interview Memo at 5.

148

Deai Interview Memo at 2, 3.
Molloy dep. at 38-39.
148
Jackson Interview Memo at 2.
149
Memorandum from Robert Adamcik, FDAA, to W.
Wilcox, "Three Mile Island Incident," at 1, April 7, 1979.
150
Kuehn dep. at 12, 13.
151
John McConnell Interview Memo at 8.
147

1056

D INFORMATIONPROVIDED TO THE
NEWS MEDIA AT
THREE MILE ISLAND
1. INTRODUCTION
This section addresses and evaluates State,
NRC, and Met Ed interactions with the news media
during the TMI accident and presents a chronological narrative of the first 6 days following the accident. It discusses the views of national wire service and television network representatives, as wellas the feelings of Met Ed officials on why the utility
lost its credibility with the news media. Additionally,
it presents commentary from the news media on
factors which affected the performance and credibility of the NRC in its dealings with the news media.
It will then examine the impact of the manysources of information that existed during the first 4
days of the accident and, finally, presents our findings on how well these organizations informed the
public during the course of the accident and ourrecommendations for improving the flow of information to the public in the event of another accident.
Press conferences and public announcements
were the principal vehicles of public information.

Met Ed and the State depended on one or two dailypress conferences, while the NRC depended solely
on public announcements for the first 2 days. BothMet Ed and the NRC appointed public affairs offices
to handle phone inquiries, and both organizations
l ater discontinued these operations and establishednews centers near the site.
Key State individuals involved in media relations
i ncluded Lt. Governor William Scranton, who acted
as spokesman, until this position was taken over by
Governor Richard Thomburgh when he held his firstpress conference on Thursday, March 29. The
Governor was assisted by Press Secretary Paul
Critchlow.
The key NRC individuals involved in the NRC's
relations with the news media include: Harold Denton, who became the NRC's principal spokesman
after he arrived at the site on Friday, March 30;
Joseph Fouchard, the NRC's chief public affairs officer, who served as Denton's liaison with the news
media; Karl Abraham, regional assistant toFouchard, who was initially the NRC's media contact

105 7

i n Harrisburg and who later assisted Fouchard in
Middletown; Frank Ingram, assistant to Fouchard,
who served as liaison with the news media at the
NRC Headquarters; Chairman Joseph Hendrie, who
held a news conference at the NRC Headquarters
on Saturday, March 31; and Dudley Thompson, whoparticipated in a news conference held at the NRC
Headquarters on Friday, March 30.
There were a number of key Met Ed individuals
who met with the news media: Jack Herbein, Met
Ed Vice President for Generation, became the principal spokesman for the company; Walter Creitz,
Met Ed President, appeared on two nationwide
television programs on Thursday morning and latermade the decision to discontinue Met Ed's standup
news briefings; Blaine Fabian, Met Ed Manager ofCommunications Services, was in charge of theReading operation and later the Hershey News
Center; and George Troffer, Met Ed Manager of
Quality Assurance, acted as the principal technicaladviser to the utility's Reading Communications
Department and later to the news center staff.
Herbein relied on two plant officials, George
Kunder, Superintendent of Technical Support of
TMI-2, and Gary Miller, Station Manager, to provide
up-to-date information on the status of the plant.
Kunder, who was the officer on call Wednesday
morning, arrived at the plant at about 4:45 a.m. toobserve plant recovery from a transient induced
shutdown. He found the plant in an unusual condition. The primary coolant system appeared to contain too much water, yet system pressure was low.
Kunder had been taught that a full primary coolant
system was always associated with a high pressure
condition.
Miller, who was preparing to go to a meeting in
New Jersey, had been notified of the reactor trip
shortly after 4:00 a.m. and was advised that no
conditions out of the ordinary existed. At about 5:15
a.m., Miller placed a call to Kunder, and Kunder explained the unusual plant conditions. Miller thendirected additional personnel to the plant to assist.
He next set up a conference call to discuss themorning's events with Kunder, Herbein (who was inPhiladelphia for naval reserve training), and Lee
Rogers, Babcock & Wilcox's onsite technicalrepresentative. The information conveyed to Herbein in this conversation would provide the information base for Met Ed's first public statement.
2. CHRONOLOGY
Wednesday, March 28

Met Ed's Jack Herbein first learned of the trip at
TMI-2 during the conference call discussed above.

Herbein, under the impression that the plant situation was stable, placed a call to Blaine Fabian in
Reading, Pa., at approximately 7:15 a.m. The purpose of his call was to prepare Fabian for handlingi nquiries from the press and from the general publicconcerning the reactor trip. Fabian drafted a shortpublic statement which advised simply that thereactor had tripped because of a feedwater malfunction and would be out of service for about aweek. According to Fabian, the statement was kept
brief because information concerning plant status
was still preliminary. The purpose of the statement
was primarily to advise the public that, first, a problem existed and, second, that the utility was working
to solve it. Shortly after the statement was drafted,
Fabian was notified, probably by Herbein, that ageneral emergency had been declared. He did noti nclude this information in the initial public statement,
however, because the draft statement had alreadybeen agreed upon. 1
Shortly after 8:00 a.m., Fabian met with membersof his professional and clerical staff to discuss themorning's events. They had begun discussing theneed to have background information on the TMI
units available, for the purpose of answering media
i nquiries, when the telephones began ringing. Fabian released his three available professional communicators to respond to the calls and instructed
his staff to respond to inquiries by reading the public statement and providing background informationon the TMI plant.
Meanwhile, a reporter from a Waynesboro, Pa.,
newspaper was making a routine morning checkwith the State Police and learned there had been aproblem at TMI and that a general emergency had
been declared. This information was passed on to
the Associated Press (AP) Philadelphia Bureau andthen to the Harrisburg Bureau. A reporter from theHarrisburg Bureau attempted to confirm the information with Met Ed in Reading, but was unable toreach a spokesman. The reporter then called thePennsylvania State Police, who confirmed the report
but could not say what constituted a general emergency. At 9:02 a.m., AP put a national bulletin over
the wires stating there had been an accident at TMI,
that no radiation had been released, and that a general emergency had been declared; no details wereas yet known, and a company spokesman was notavailable. This was the nation's first notification that
there had been an accident at TMI.
Shortly after 8:30 a.m., Fabian went to Walter
Creitz's office and assisted Creitz in answering callsfrom the media and from Government officials. It
was during this period that Fabian learned that conflicting reports were circulating that radiation
releases to the environment had been detected.
105 8

Fabian then requested George Troffer, who had
been enlisted by Fabian to act as technical advisor
to communication services, to determine whether
there had been any such releases.
Troffer contacted Gary Miller at about 9:30 a.m.,
and was advised by Miller that there had been no
known releases to the environment. Miller also told
Troffer that reactor coolant had been released to
the reactor building floor and that there might havebeen some fuel pin leakage, but that there was noi ndication of melted fuel. Miller also said a generalemergency had been declared because plant instrumentation indicated high levels of radiation in thereactor containment building dome area, but that noreleases were expected. Miller added that no one
had been overexposed, but that in the actions
necessary to reach cold shutdown someone might
be. Finally, he noted that efforts were still being
made to bring the plant under complete control. 2
Based on Troffer's conversation with Gary Miller,
Fabian and Creitz drafted an updated statement by
10:00 a.m. This statement advised that the generalemergency plan had been implemented because radioactive water had been released inside the containment building, but that monitoring had detected
no external radiation releases and no such releases
were expected. The 10:00 a.m. statement was provided to the communication services personnel, who
would not confirm releases to the environment.
The small communication services staff was
overwhelmed by the large number of incoming
phone calls and was unable to return calls. As soon
as one call was completed, another incoming callwould have to be accepted. As an indication of theseriousness of the problem, the AP Harrisburg
Bureau did not receive a call from Met Ed on Met
Ed's initial 7:30 a.m. statement until shortly before
10:00 a.m. In order to cope with the high volume ofi ncoming calls, communication services clerical andadministrative personnel, as well as volunteers andi ndividuals recruited throughout the company, began
answering phone calls. Many of these individuals
were unable to provide any other information thanthat contained in the public statement.
Although the NRC was notified of the accident by
Met Ed at 7:45 a.m., it was not until after AP broke
the story that reporters began flooding the NRC withcalls. Some of these calls were directed to the NRC
Regional Office in King of Prussia, Pa., which had inspection responsibility for the plant. Others weredirected to various NRC Headquarters offices located in Washington, D.C., and Montgomery County,
Md. Since reporters did not initially know who in
the NRC to call for information concerning the accident, inquiries were made to several different offices. This hampered the NRC's ability to handle

the incoming calls and to assure that information on
the accident was consistent.
The NRC did not issue a public announcement
concerning the accident until 10:30 a.m. This announcement stated that the NRC had received preli minary information that there had been a release ofradioactivity inside the reactor containment building.
It also stated that measurements to determine
whether there had been an offsite release were bei ng made, that some reactor coolant water had beenreleased into the containment building, that the emergency core cooling system was being used toprovide water to the reactor, and that the reactor
had been shut down. Apparently, the announcement could have been released much earlier. It wasdelayed, however, while the NRC attempted to obtain additional details on the accident. It appears
too that the release was delayed by the timeconsuming process of obtaining staff and Commission concurrence on what should be said.
At 7:02 a.m. Met Ed notified the Pennsylvania
Emergency Management Agency (PEMA) about thesite emergency declaration and requested that
PEMA notify the State Bureau of Radiation Protection (BRP). Upon learning of a general emergency
declaration, PEMA notified Governor Thornburgh at
7:50 a.m. Lt. Governor Scranton was informed of
the situation when he arrived at his office at 8:20
a.m.
Scranton called the TMI-2 control room shortly
after 9:00 a.m., and was briefed on plant status byGary Miller. Miller provided Scranton with essentially the same information, but in less detail, that Miller
would discuss with Met Ed's George Troffer in their
9:30 a.m. conversation.
Based on this information, the Lt. Governor held
a press conference at 10:55 a.m., and announced
that the State had been informed of an incident at
TMI-2, but that he had been advised that everything
was under control and that there was no danger topublic health and safety. He stated that Met Ed had
been monitoring near the plant and that no increasein normal radiation levels had been detected. He
also reported that PEMA had notified the counties inthe vicinity of the plant, although there was no needfor evacuation. Available to answer questions with
the Lt. Governor were: William Dornsife, BRP; Oran
Henderson, PEMA; Senator Jim Ross, a member ofthe Emergency Management Council; Bob Laughlinof the Governor's Science Advisory Committee; andRay Holst, Energy Liaison Officer. Questions following the Lt. Governor's prepared remarks concerned the cause of the accident, its seriousness,whether any employees had been exposed, whether
there were dangers due to offsite radiation, and why
there had been a 3-hour delay from the initiation of1059

the incident to notification of State agencies. Because of the limited information available about theaccident, the Lt. Governor was forced continually torespond to reporters' questions by explaining that
the State did not yet have any details regarding thei ncident. During the question and answer session,
however, Dornsife reported that small amounts ofradioiodine had been detected by the monitoring
teams, information that had not been provided to the
Lt. Governor prior to the briefing. This informationl ater proved to be false and only added to themorning's confusion.
At 11:45 a.m. Troffer notified Creitz and Fabianthat above background radiation levels had been
detected at the observation center and at the siteboundary. Based on this information, Fabian andHenry Robidoux, Vice President of Operations,drafted Met Ed's third public statement, a statement
approved by Creitz. Far from acknowledging readi ngs above background, Met Ed's statement readthat "there had been no recordings of any significant
levels of radiation and none were expected outside
the plant." The statement also advised that no evacuation of the local population was needed at thattime. 3
Shortly before noon, Herbein arrived at the observation center where members of the news media,
i ncluding television crews from the national networks, had been anxiously awaiting the appearanceof a Met Ed spokesperson. Herbein and Creitz discussed what should be done with respect to themedia. They agreed that Herbein would hold an impromptu news conference. Herbein also was instructed to go to the State Capital when he was finished talking to the press to brief the Lt. Governor.
After he received an update on the status of TMI-2
from plant personnel, Herbein briefed a group of
about 30 reporters outside on lawn at the observation center. Herbein briefly described the accident
sequence, indicated that no one had been injured,and related that radiation measuring only 10% of thegeneral emergency level was being monitored at thesite boundary. He also described the conditions in
the reactor building that led to the site emergency
declaration and stated that there was possibly asmall amount of damaged fuel. The briefing, whichbegan at 1:15 p.m., lasted about 40 minutes.
Herbein did not mention during the briefing thatsteam had been vented to the atmosphere in an effort to cool down the plant but that just prior to thebriefing he had ordered the venting stopped because he wasn't sure whether or not the steam wasradioactive. Met Ed apparently did not tell State officials of the steam venting until after the fact, nor

did Herbein volunteer this information until it was requested during his briefing of the Lt. Governor at
2:30 p.m. State officials, who believed the steam
was the source of offsite radiation, were extremely
upset, and believed that Met Ed was deliberately
holding back information that the State needed toevaluate the accident's impact on public health andsafety. This perception by the State was aired publi cly during a 4:30 p.m. press conference held by
Scranton. In attendance were Domsife of BRP,
Henderson of PEMA, and Gerusky of BRP.
The Lt. Governor's prepared remarks stated thatthe situation at TMI was more complex than theState had been led to believe originally, but that
State officials believed there still was no danger topublic health. The Lt. Governor stated that Met Ed
had given misleading information to the State and to
the public, but that he had just met with company
officials and hoped that the press conference would
clear up any questions. He stated that radiation had
been released from about 11:00 a.m. until 1:30 p.m.
while the plant was venting steam as part of the emergency cooling process. Apparently, he reported,a leak in the primary system had allowed radioactivity to get into the steam. (This was not correct;
there had been no radioactivity in the steam, butsince radiation was measured after steam venting
had been started, a connection between the steam
venting and the radioactivity release was presumed
to exist.) Scranton stated that the State had notbeen aware of the release until near the time it was
halted, but that Met Ed had promised to notify theState in the event further steam discharge wasnecessary. He stated that radiation levels were
below any existing or proposed emergency actionlevels, but that the State was concerned because
any increased exposure constitutes a danger tohealth. Scranton said that teams from the State
Department of Environmental Resources (DER), the
NRC, and the Department of Energy (DOE) were in
the area conducting measurements, and that reports indicated that radiation levels had been decreasing throughout the afternoon.
During the question and answer session, State
officials went on to say that Met Ed had advised
them that the company had followed normal procedures in its initial notification of State officials
concerning the accident, that a chest X-ray isequivalent to 20-100 milliroentgens, that radioactivity
leakage had decreased since the steam venting had
stopped, that there was no potential for high radioactivity releases to the environment, and that theplant could be shut down for a matter of weeks.
On Wednesday afternoon Creitz, at Fabian's urg-

1 060

i ng, agreed to hold a press conference on Thursday
morning. They also agreed that Herbein, despite hislimited public relations experience, should be theprincipal spokesman because his technical background would enable him to respond in detail toquestions posed by the media. The Hershey Convention Center was selected as the site for thepress conference because of the availability of telephones for the press and the overall adequacy of
the facility. Fabian had worked out the logistics forthe press conference by 4:30 p.m. Fabian later
stated that he advised Karl Abraham, the NRC Region I Public Information Officer, of the plan and thenasked Abraham to participate. Abraham called Joe
Fouchard, the NRC Public Relations Director, andwas instructed not to take part in any news conference held by Met Ed because the NRC wanted tostay in the "investigative mode." 4 This was the firstof three occasions on which the NRC rebuffed requests by Met Ed for joint press ventures. The
NRC's position on this subject was a major contributor to the problem created by multiple sources of
information, a problem discussed later in this report.
The number of phone calls from the media hadreached the point that Met Ed communicators foundit i mpossible to draft additional public statements.
Staff answering phone inquiries were updated verbally by technical personnel who were in contact
with the plant and the observation center. Information on plant status, however, was still sketchy. The NRC was also experiencing problems withthe huge influx of phone calls from reporters andothers during the first several days of the accident.
Inquiries were mostly answered by the NRC's seniorpublic affairs personnel and by designated technicalstaff. Some calls, however, were answered by the
NRC's senior management staff in the Incident
Response Center, who had to stop other importantwork for this purpose. While most calls requested
updated reports on the accident, some requested
television and radio appearances by NRC staffers.
A number of these requests were honored, but others were refused in an effort to limit the number ofagency spokespersons.
Met Ed was also receiving requests for televisionappearances by company spokespersons. Late on
Wednesday afternoon, Creitz and Fabian discussedwith GPU management the feasibility of having
Creitz appear on Thursday morning on the "Good
Morning America" and "Today" shows.
GPUmanagement agreed that Creitz should appear.
After the discussion, Fabian made arrangements formanning the telephones Wednesday night. Communicators were moved to a location with central-i zed phones and facilities for communicating directlywith news media representatives if necessary.
Three communicators were directed to call thenews media to advise them of the news conference
scheduled for 10:00 am. Thursday in Hershey. Arrangements were also made for an all-night operator, who was told to read the public statement tocallers and advise them of the Thursday press
conference.
The NRC issued a second public announcement
at 5:00 p.m. It stated that low levels of radiation had
been measured offsite, but that these levels of radiation were believed to be prinicipally attributable todirect radiation coming from the containment buildi ng rather than from the release of radioactive materials into the environment. The announcement
stated that the sequence of events which led to therelease of radioactivity into the containment building
had not been determined. In retrospect, this announcement substantially understated the significance of the accident and was in error regarding
the source of the radiation levels detected off site.
It is apparent that the NRC officials were not at thattime fully aware of plant conditions. Had the NRC
officials known that core temperatures above 2000
degrees had been measured that morning and thata hydrogen burn had occurred in the reactor building that afternoon, their perception of the seriousness of the accident would have been substantiallydifferent.
Additionally, the offsite radiation levels were not
the result of direct radiation from the reactor building. The source of these radiation levels was radioactive gas being emitted from the plant into the
air of surrounding communities. The inadequaciesof this press release can be attributed to the poor
quality of information flowing from the site to the
NRC Headquarters on the first day of the accident.
The small team of NRC inspectors on site atThree Mile Island Wednesday and Thursday was sobusy collecting data and manning telephones thatthey could not communicate needed information tothe outside. Also, telephone lines were so tied upthat phone connections between inspectors andoffsite NRC staff were frequently not possible forlong periods of time. These problems resulted inconsiderable confusion and would later cause people to question the reliability of certain information
given out by the NRC.
At 8:45 p.m. Charles Gallina and James Higgins
of NRC Region I and Bob Friess of the DOE met
with Lt. Governor Scranton and other State officials
to discuss the plant status. At 10:00 p.m., following
this meeting, the Lt. Governor held the State's third

1 06 1

press conference. Gallina, Higgins, and Friess attended. Scranton announced that he had been advised that there currently was no radioactive leakage from the reactor containment; however, there
was radioactivity in the auxiliary building, and there
was some dispersion of this material into the atmosphere when the auxiliary building was vented. Thisi nformation directly contradicted the NRC's 5:00
p.m. press release. Scranton further stated that
there were some high, but not critical, levels of radioactivity on site, but that no critical levels of radioactivity had been detected off site. He thenopened the floor for questioning of the NRC
representatives.
Reporters were told that there was no permanent
damage to the plant, there appeared to have been a
primary system to secondary system leak, there
was no indication of human error, there had beensome damage to the fuel but it didn't appear to be
severe, and that the reactor was stable.
Region I's Karl Abraham, who had earlier informed Joe Fouchard that he, Abraham, could be
more effective at the site, listened to a radio broadcast of this press conference as he drove to Harrisburg. Finding the observation center virtually
without phone communications, Abraham set up
shop in Paul Critchlow's office there.
Circumstances were to dictate that he was not to play
an instrumental role in the NRC's interaction with thenews media. He found himself virtually isolated from
NRC activities at TMI-2, a situation illustrated by thefact that Abraham was not notified of the arrival of
the NRC Headquarters team on site. Consequently,
Abraham was unable to use the team as a source of
information on Thursday, and on Friday he assumed
the task of funneling information from the NRC
Headquarters to the Governor's office and, later, ofhandling the logistics for setting up the NRC press
center. Thus, he was stripped of any responsibility
for acting as a public spokesperson.
As the first day of the accident came to a close,
Creitz arrived at the observation center to be
briefed for his Thursday morning television appearances on "Good Morning America" and the "Today"
shows. Creitz was briefed a second time prior to
his appearances by George Kunder and Joseph Logan, the TMI-2 Superintendent. As midnight approached, Creitz held a short, general briefing forthe reporters still on the observation center lawn,
and after the briefing he left the observation center.
Thursday, March 29

The NRC issued its third public announcement
shortly after midnight. It stated that reactor tem-

peratures had continued to drop, but not far enoughto activate the normal decay heat removal system.
The statement further indicated that a radiation levelof thousands of roentgens per hour existed inside
the containment dome and that there had been acontinuing release of radioactive gases to the atmosphere, releases said to have come from water that
had been pumped over from the containment buildi ng to the floor of the auxiliary building. Radiation
measurements were reported to be 1/3 milliroentgen
per hour in the air over the Harrisburg area and 12
milliroentgens per hour at ground level at the Harrisburg airport. The announcement went on to saythat these radiation levels were far below the levelat which the Environmental Protection Agency (EPA)
recommended protective action. Eight Met Ed
workers were reported to have received radiation
doses of up to 1 rem during the day's activities. The
reference to EPA Protective Action Guides was
somewhat confusing because the announcementi mplied that the guides are based on dose rates, i.e.,
milliroentgens per hour, when in fact they are basedon accumulated radiation doses, i.e., total milliroentgens. To avoid confusing the public, the
NRC's statement should have explained the significance of all reported information. This public announcement was the last the NRC would issue for
42 hours.
Although Met Ed management believed the plant
was fully under control, the core was not cooling
down as rapidly as expected. The reasons for theslow cooldown were the physical disarrangement of
the core and the presence of steam and hydrogengas in the reactor coolant system. This situation
was not generally known by the plant staff. The
staff was also unaware that radioactive gas was beginning to accumulate in the makeup tanks.
At 5:00 a.m. Creitz taped his appearance for"Good Morning America" at the WTPA studio in
Harrisburg. ABC news correspondent Bettina Gregory was with Creitz in Harrisburg, and David Hartman, host of the show, and Daniel Ford, Executive
Director of the Union of Concerned Scientists, werein ABC's New York studio participated in the taping.
This segment of the show was aired at 7:15 a.m.
During the broadcast, Creitz stated that radiation
l evels outside the plant were low, that no Met Ed
employee or member of the public had been exposed to radiation levels considered dangerous, andthat radiation releases had been substantially reduced. The plant was safely shut down, he said,
and was under control; radiation levels in the containment building were high, but Met Ed would not
be able to evaluate the seriousness of the problem
without further study.

106 2

unable to understand and by his inability to provide
complete answers to their questions. The press
conference lasted about 90 minutes.
On Thursday afternoon Fabian discussed future
media relations with Bill Murray, GPU Vice Presidentof Communications, and Richard Hyde. Hyde, aVice President of Hill and Knowlton, a large New
York-based public relations firm, had volunteered
his services to Met Ed. They decided to set up a
news center in the Hershey Convention Center tohandle day-to-day inquiries from the media andfrom the general public. They also agreed to holdfuture press conferences at the American Legion
Hall in Middletown.
Earlier in the day, Lt. Governor Scranton had
toured TMI-2. Based upon information gained by
Scranton, Governor Thornburgh held a press
conference at about 5:15 p.m. The Lt. Governor,
Gerusky, Higgins, Gallina, and Henderson were inattendance. The Governor stated his belief that
there was no cause for alarm, no danger to publichealth, and no reason to disrupt daily routines. He
noted the conflicting information that had been received and stated that Lt. Governor Scranton had
visited the plant to obtain a layman's impression of
the situation. He stated that, though the situation
appeared to be under control, it was important toremain alert and informed.
I n response to reporters' questions, Higgins andGallina, from the NRC, stated that the plant was approaching cold shutdown, radiation levels had been
greatly reduced, a preliminary evaluation had shownno human error (contradicting an earlier report fromthe NRC Headquarters), and that the danger wasover for people off site. This last remark later
resulted in criticism of the NRC by State officials
and the media.
Unknown to NRC participants at this press
conference, the potential danger for people off site
was far from over. By this time, plant personnel had
realized that a noncondensible gas bubble in thereactor coolant system was impeding the flow of
coolant to the core. This bubble would prove to be
the source of much public confusion and alarm overthe next 2 days.
About midnight, in a press release issued by Clifford Jones, DER Secretary, the discharge by Met
Ed of industrial wastewater containing small concentrations of xenon into the Susquehanna River
was announced. The press release stressed thatthe discharge did not add harmful radioactive pollution to the river. The discharge, the report stated,also ended a half-day effort on the part of the utility
to dump the wastewater. It also ended a protracted
dispute between the NRC and the State over who

At 7:47 a.m. Creitz and Ford appeared with Tom
Brokaw, NBC news correspondent, on the "Today"show, and Creitz reiterated essentially the same information he had discussed earlier on "Good Morni ng America."
At about the same time, Herbein appeared on
CBS's "Thursday Morning," as previously agreed
with Creitz and Fabian. CBS news correspondents
Gary Shepherd and Bob Schieffer participated in
the broadcast, which was conducted at WHP studios in Harrisburg and went on the air at 7:30 a.m.
During the broadcast, Herbein advised that the plant
was stable. Plans were to switch to decay heat removal later that day, at which point the plant would
be in the cold shutdown condition. He said that
trace amounts of radiation were still leaving the siteboundary and there were high levels of radiation in
the reactor building, although one monitor was believed to be giving an erroneous reading. There
were 2 to 3 feet of water on the reactor building
floor, action was being taken to reduce the trace
amounts of radiation escaping from the water on thefloor of the auxiliary building, and there had beensome fuel failure. Safety systems functioned as
designed, and it was hoped that releases to the environment would be over in about two days.
Met Ed held its first formal press conference in
the Aztec Room of the Hershey Convention Centerat 10:00 a.m. Thursday morning. The large turnoutof media representatives, over 100, had not been
anticipated by the utility and was described by Met
Ed officials as overwhelming.
Creitz, after making a brief opening statement,
turned the press conference over to Herbein for thesubstantive briefing. Herbein made a few optimistic
comments on plant status and then opened the floor
to questions. In keeping with a generally optimistic
tone, he provided a relatively detailed sequence of
the accident and stated that the utility hadn't ruledout the possibility of human error in the accident.
Most of the paths leaking radiation from the auxiliarybuilding, he said, would be closed off by the day'send. Perhaps .5% to 1% of the fuel rods had melted
somewhat, and Met Ed was not certain of the periodof time the core had been uncovered. The plant
would be in a cold shutdown condition by late thatnight or by the next morning. Toward the end of thepress conference, both Herbein and the reporters
were somewhat irritable. Under intense questioning
on the dangers of radiation, Herbein responded, "I
can tell you that we didn't injure anybody in this accident, we didn't overexpose anybody and we cer5
tainly didn't kill a single soul ...." Observers of thenews conference felt that reporters were frustrated
by Herbein's use of technical jargon that they were106 3

would take public responsibility for authorizing thedischarge.
Friday, March 30

Although plant status did not change significantly
from Thursday night, pressure resulting from noncondensible gases in the primary coolant system
had built up in the makeup tanks. In an effort to relieve this pressure Met Ed's James Floyd ordered
the gas transferred to another tank. Primarily because of leaks in the transfer system, however, thisoperation resulted in a continuous release of gas tothe atmosphere, beginning about 7:30 a.m. A helicopter monitoring the release recorded a spikemeasurement of 1200 milliroentgens at about 8:00
a.m. This measurement was reported to the State,
to the NRC, and eventually to the press, none ofwhom had been notified in advance of the venting
operation. The news of this release dramatically altered the perceptions of the news media and the
public concerning the seriousness of the accident.
The information about the release was misinterpreted by the NRC Headquarters, and Chairman
Hendrie advised the Governor that people within 5
miles of the plant in the downwind direction should
be told to stay indoors. The Governor made thisannouncement in a live broadcast on WHP radio at
10:25 a.m., altering Hendrie's recommendation andsuggesting that people within a 10-mile radius of theplant stay indoors and keep their windows closed.
Shortly after this broadcast President Carter
conferred with Hendrie. Subsequently, because thePresident wanted a responsible senior official totake charge on behalf of the Federal Government
and to be his direct contact, Harold Denton was
sent to the site to represent him. Then, in an 11:15
a.m. conversation with the President, Governor
Thornburgh complained he was being given diverse
information about what was happening at the plant.
Carter advised Thomburgh that Denton was goingto the site to be the President's representative andthat Denton would be the primary source of information on reactor status for the President and for
the Governor. It was never intended that Denton
would have a public information role. This would
quickly change.
Following Denton's Friday night briefing of theGovernor, the Governor asked Denton to join him at
a press conference to field questions about theplant. Because there were conflicting reports aboutplant status, the White House, with State urging,
evolved a press policy by which Denton would be
spokesman for all information on plant status. In
addition, Jody Powell would be the sole spokesman

regarding Federal emergency assistance and theGovernor would be the only public spokesman on
matters of evacuation and emergency response.
Met Ed held its second press conference at 11:00
a.m. on Friday morning, and Herbein again was principal spokesman. Reporters were concerned andwere openly skeptical of Herbein because of thedramatic change in the public's perception of theaccident, a change caused by the reported radiation
releases earlier that morning and the advisory fromthe Governor. Herbein, who had just spoken to thecontrol room, explained the planned venting procedure which led to the release and said that therelease was measured at between 300 and 350 milliroentgens per hour. Herbein was unable torespond to reporters' contentions that plant officials
told State officials that the release had been uncontrolled. He also maintained that he had not heard of
the 1200-milliroentgen measurement cited by theState and the NRC, but did not dispute the reading.
Herbein informed reporters that the venting would
probably need to be repeated over the next 5 days.
The atmosphere at the press conference grewincreasingly heated. The confusion caused by conflicting reports on the day's events and by reporters
who had just arrived on site and were still catching
up on basic information irritated reporters who had
been at the site since Wednesday and were alreadyfamiliar with the accident. Shouting matches for
Herbein's attention ensued. The situation was intensified when Herbein, responding to a question on
why the press hadn't been notified of the wastewater discharge to the Susquehanna River, remarked,"I don't know why we need to tell you each andeverything that we do ...." e This statement was interpreted by some reporters as a refusal by Met Ed
to volunteer information concerning the health andsafety of the public. As an engineer, Herbein probably viewed the discharge of the wastewater as apart of normal plant operations and totally separate
from the accident, thus not newsworthy. In fact, theradioactivity was well below regulatory limits forroutine discharge to the river.
It is notable that Met Ed did not make available
an experienced public relations official to be with
Herbein at the company's press briefings. Such an
official could have explained Herbein's probable rationale for the remark, thus minimizing its adverse
i mpact.
Herbein advised reporters that cold shutdown
could not be achieved for 5 days because of hightemperatures in five fuel assemblies. After thequestion and answer session, Herbein explained theaccident sequence by use of charts and graphs.
At about 12:30 p.m. Governor Thornburgh, after1064

conferring a second time with Chairman Hendrie,held a press conference at the capital. Lt. Governor
Scranton, Gerusky, and Craig Williamson of PEMA
were also present. The Governor announced that
he had been in contact with the President and with
the Chairman of the NRC. He stated that the
President concurred in the Governor's views that
there was no reason for panic or implementation of
emergency measures, and that the President should
dispatch Harold Denton to the site as his personal
representative. The Governor also announced that,based on the advice of the NRC Chairman and in
the interest of taking every precaution, he wasadvising that pregnant women and preschool-age
children within 5 miles of the plant leave the area.
He also ordered the closing of schools within the
5-mile radius. During the questioning following the
prepared remarks, he extended the earlier "stay indoors" advisory to "until further notice." (It should
be noted that PEMA had already sent a teletype tothe counties lifting the first advisory.) In response toreporters' questions concerning evacuation planning, the Governor said that though evacuationplans were ready he was not declaring an alert.
Reporters and State officials spent the remainder ofthe press conference discussing the significance ofradiation readings and cumulative doses.
By noon on Friday the Met Ed news center in the
Hershey Convention Center was operational. The
news center had six phone lines, one of which wasreserved for outgoing calls. The news center staff
comprised professional, technical, and clerical personnel from GPU Corp. and its three subsidiary utilities. Richard Hyde acted in an advisory capacity.
The purposes of the news center were to confirm
known factual information, provide technical explanations (technical calls were to be referred totechnical advisors), and provide background information on normal TMI operations. Reporters, however, were sometimes successful in wheedling individual views on events from members of the staff.
Updated information was to be provided to the staff
by the technical advisors, who were in contact withthe observation center. This approach did notprove entirely effective because personnel in theobservation center were often too busy to speak to
the news center staff. Too, the rapidly changing
plant status quickly made information obsolete.
At about this time, in Bethesda, the NRC was setting up a press center in the East-West Towers
Building directly over the Incident Response Center.
Commissioner Gilinsky had received a suggestion
from Jody Powell that a press center be established, and directed Frank Ingram to handle thematter. (One TV network executive reported that
106 5

he had been requesting since Thursday that the
NRC and the White House set up a press center.)
The NRC held its first briefing at the press center
shortly after it became operational. It was during
this briefing that a member of the NRC senior technical staff, Dudley Thompson, in response to areporter's question, suggested that, although there
was no imminent possibility of a meltdown, it could
happen if conditions worsened.
Thompson's statement was carried as the lead inmany national stories, often neither qualified nor put
i n its proper context, thus causing a great deal of
alarm among the public. The Met Ed news center
received a flood of calls after Thompson first publicl y raised the possibility of a meltdown. The staff at
the news center advised callers that based on
current plant parameters the possibility of a meltdown was extremely remote. The news center continued to handle inquiries until about 1:00 a.m. on
Saturday, when calls abated.
Early Friday afternoon Denton, accompanied by
Joe Fouchard, arrived at TMI-2. Shortly thereafter
Denton was approached by Met Ed officials andwas asked to concur in a joint NRC-Met Ed press
release. Fouchard felt the proposed release portrayed too optimistic a picture of plant status, andrefused the request.
At 6:30 p.m. NRC issued its first public announcement on the accident since shortly after midnight on Thursday morning. It stated that Chairman
Hendrie had said there was no imminent danger of acore melt. The announcement reported also that
additional NRC technical experts, headed by Harold
Denton, had reached the site earlier in the day.
Some further information informed that reactor fueltemperatures were coming down so slowly that final
depressurization of the reactor vessel had been delayed. There was evidence of severe fuel damage,
samples of primary coolant indicated high levels ofradioiodine, and a large bubble of noncondensible
gas was present in the top of the reactor vessel.
The announcement went on to say that if the pressure were further decreased and the gases were allowed to expand, there was a possibility that theflow of reactor coolant might have to be interrupted.
If this were to occur, there could be some additional
fuel damage. Several options were under consideration for reaching a final safe state for the fuel.
Radiation levels in the immediate vicinity of the plant
were reported to be 20 to 25 milliroentgens perhour while offsite levels were reported as a few milliroentgens per hour.
Subsequently, information was provided by the
NRC primarily through news conferences or on a
personal request basis. Some information was also

recorded for playback on special phone lines, but
this system was not widely used and did not satisfy
many callers.
At 8:30 p.m. Denton met with the Governor togive him a status report. Following this meeting, atabout 10:00 p.m., they held a joint press conference.
The Governor announced that he had decided,
based upon information he had obtained from Denton, that no evacuation order was necessary,
though his earlier recommendation regarding pregnant women and preschool-age children staying outof the 5-mile area around the plant would remain in
effect at least until Saturday. His earlier advice thatpeople stay indoors within 10 miles of the plant
would expire at midnight. Denton, responding to reporters' questions, provided the reporters with his
evaluation of the plant status, the problems Met Ed
and the NRC were facing, and tentative plans for the
future. He stressed that there was no possibility ofan explosion in the reactor vessel and that he considered the possibility of a core meltdown very remote.
Saturday, March 31

Plant staff were continuing the procedures for removal of the hydrogen from the reactor and related
systems. During the morning Met Ed and GPU officials discussed the problem of conflicting reports, aproblem created by spokespersons' making differi ng statements at different times. In an attempt toeliminate this problem, Creitz asked Fouchard toparticipate in a joint press conference, but Fouchard
again refused to join with Met Ed. Creitz then decided that Met Ed would discontinue its daily news
briefings, and he notified the NRC of his decision.
Creitz began Met Ed's 11:00 a.m. Saturday news
conference with an announcement to that effect andsaid that further public information would be provided by the NRC. The conference was again held in
the American Legion Hall, which was jammed with
reporters. Following Creitz's opening remarks, Herbein provided a briefing on plant status and told reporters the utility had attempted, to the best of its
ability, to provide the press with whatever information was available at all times. During the question
and answer session Herbein stated that he personally felt that the crisis was over. 8 Only an hour later
Harold Denton told reporters the crisis was not
over.
These two statements, widely contrasted by the
media, brought down severe criticism on the utility
for being unduly optimistic.
Herbein also commented during the question andanswer period that the hydrogen bubble had been

reduced by a third since Friday, a statement alsol ater disputed by Denton. Herbein went on to saythat offsite radiation readings were only 3 to 5 milliroentgens per hour, the core was severely damaged, and four workers had been overexposed.
Shortly after Met Ed's press conference, Denton
held his first briefing in the NRC news center at the
Middletown Borough Hall, a center hurriedly established with assistance from Congressman Allen Ertel. Equipping the center was substantially facilitated by the availability of communications equipment
provided by the White House. It was during thispress conference that Denton refuted Herbein's
earlier statement that the crisis was over. He said
the crisis would not be over until the reactor was ina cold shutdown condition, but indicated that he did
not think the hydrogen bubble posed an explosion
problem at that time.
Shortly after the NRC news conference in Middletown, Chairman Hendrie held a news conference
at 2:45 p.m. in Bethesda. He reported that thereactor was stable and the fuel was continuing tocool, that the gas bubble would have to be removed
from the reactor, and that small releases of noble
gas fission-product activity were continuing. In
answer to a question on evacuation, he indicatedthat evacuation was a possibility that would have to
be kept in mind in considering the steps to be taken, that evacuation might turn out to be a prudent
precautionary measure, and that evacuation would
be considered as far out as 20 miles. Regarding the
bubble, Hendrie stated it would be some time before
any possibility of a flammable condition existed.
Hendrie was also asked to confirm Herbein's earlier
statement that the bubble had decreased in size by
a third. He responded that Herbein had been talking
not about the bubble in the reactor but about another bubble, which was in the pressurizer. Hendrie's
statement further confused the bubble story because Herbein had, in fact, been talking about the
bubble in the reactor vessel. 9
Chairman Hendrie's news conference botheredsome of the reporters at the site. They wondered
why a second news conference in Bethesda wasscheduled when Denton had presumably said all
there was to say at his earlier news conference.
One hypothesis was that perhaps Chairman Hendriewould announce bad news which, for obvious reasons, should come from the NRC Headquarters.
Following discussions with Denton and Hendrie,
Governor Thornburgh issued a press release atabout 5:00 p.m. The release stated that the evacuation advisory for pregnant women and preschoolage children would remain in effect for at least
another night. It also related that wider evacuations1066

were unnecessary, that decisions regarding school
closings and leave policy for State employees would
be announced on Sunday, and that there was no
threat to public health in either milk or drinking water.
The Middletown area was calm until around 8:20
p.m., when the AP, in a bulletin cleared by the NRC,
warned that the hydrogen bubble showed signs ofbecoming potentially explosive. Soon, a second
bulletin announced that an unnamed source at the
NRC had related that the bubble could explode in acouple of days. The AP story created a near panic
i n the Harrisburg area. State Police officers in thearea were flooded with calls from anxious residents
asking what they should do. Fearing an explosion
was imminent, some people left the area.
After the AP story, telephone calls to the NRC,
heavy all along, hit their peak when a TV station in
New York urged listeners to call the NRC if they had
questions about the accident. In an effort to assist
callers, the station gave out the NRC phone number.
As a result, the NRC was deluged with calls, manyfrom viewers who wanted to know if they might
have to evacuate their homes in New York or New
Jersey. A physician in New York City called to saythat he had been hearing from his patients, whowere concerned for their safety. One call to the
NRC asked, "how far do we have to get away to10
survive?"
A large number of people offered ideas and assistance, some even came from terminally ill people
who offered to enter potentially dangerous high radiation areas. Other calls came from technicallytrained people who had ideas concerning the elimination of the hydrogen bubble or the provision of increased protection.
Over time, the NRC public affairs spokespersons
were exhausted by the volume of calls. They had
worked 12 hours a day from Wednesday throughSaturday, and some of them had worked muchl onger. By Saturday night, when incoming calls significantly increased, many on the staff were so exhausted that their ability to deal with the callers was
greatly reduced.
I n Hershey, technical personnel in the Met Ed
news center were giving out an explanation on thesteps Met Ed was taking to reduce the hydrogen
bubble. These technical advisors openly disagreed
with the NRC, and were stating that the bubble
could not explode because there was neither oxygen generation nor source of ignition.
The NRC onsite technical personnel also did not
believe the bubble was explosive. When they heardthat the NRC Headquarters had approved the bubble story, they were surprised, and they openly
106 7

disagreed. They voiced this disagreement in aphone call to the NRC Headquarters and again
through a joint news conference held by Governor
Thornburgh and Denton later that night. Governor
Thornburgh also expressed deep concern to theWhite House and, as a result, the White House suggested that the NRC Headquarters stop dealing with
the news media. From then on, all calls from thenews media were directed to Denton and his staff in
Pennsylvania.
The near panic created by the conflicting reportson the status of the hydrogen bubble and the resulting AP story prompted White House aide Jack Watson to call Herman Dieckamp, GPU President, andsuggest that all future press conferences be held by
the NRC. Although Met Ed had announced earlier
that they would no longer hold press briefings, theutility was still giving out information on plant statusfrom the Hershey news center. H,12
After learning of Watson's call, Fabian called Ken
McKee of GPU at about 10:00 p.m. and told him anagreement had been reached whereby the NRC
would provide all information on plant status. Calls
on plant status received by the news center were to
be referred to the NRC, and the news center staff
was to continue only to provide background information on TMI and confirm existing public statements made by Met Ed and the NRC. One of thetechnical advisors in the news center, however, believes he continued to provide the Met Ed positionon the bubble when requested. Met Ed's news
center operated on this basis until Monday.
At about 11:00 p.m. Governor Thornburgh andHarold Denton held their second joint press conference in an attempt to alleviate some of the confusion on plant status. The Governor stated that
there had been a number of erroneous or distorted
reports during the day regarding the TMI plant andthat during his briefings with Denton he had beenassured that no imminent catastrophe was foreseeable. Thornburgh appealed to those who had reacted or overreacted to the day's reports to listen
carefully to what Denton had to say about thecurrent status. Denton opened his portion of thepress conference by stating that there was no nearterm possibility of a hydrogen explosion in either thecontainment or the reactor vessel. Reporters questioned the differences between Denton's views andthose of the NRC Washington offices on the possibility of a hydrogen explosion in the reactor and thenecessity of evacuating an area out to 20 miles
from the plant when removal of the gas from thereactor was attempted. Denton stated that he had
been in touch with the Washington offices and that
there was essential agreement on the plant status

and the courses of action open. He indicated, inreference to the differences, that reporters were
overplaying minor contradictions, and that he didn't
know how to solve the problem, except by issuingstatements from only one point. In answer to astraightforward question regarding the danger of ahydrogen explosion, he stated, "There is no physicalpossibility of it" 13 in the immediate future. Denton
discussed the procedures being used for hydrogen
control and talked about shipments of special
equipment to the site.
Sunday, April 1

At about 1:00 p.m. President Carter arrived in
Middletown with Mrs. Carter and Jack Watson.
Carter toured the plant and later gave a brief
speech in the gymnasium adjacent to the Middletown Borough Hall. Carter's visit had a reassuring
effect on local residents. One Middletown resident
remarked that Carter's presence, "has helped
morale tremendously up here-they think if it's safefor the President of the United States to come up,
it's not too bad."14 After Carter's visit, near panic in
the Harrisburg area subsided, and the news media
and the public caught its breath from the events ofthe previous 2 days. Meetings with the press also
slowed; Denton held the day's only press conference. During a briefing at 2:00 p.m., Denton repeated his belief that evacuation was unnecessary.
Steps were being taken, he said, to eliminate thebubble, and core temperatures were steady.
Although technical personnel shared a more opti mistic outlook regarding TMI-2 by that evening,
Governor Thornburgh still wanted to be cautious. In
a 7:00 p.m. press release, Thornburgh directedState offices to open as usual on Monday, April 2,
but he extended the advisory made to pregnant
women and mothers with preschool-age children tostay out of the area within 5 miles of the plant. He
also recommended that schools within the same
area remain closed until further notice. He notedthat schools elsewhere had taken independent action regarding closing, but emphasized that there
was no evidence of hazards to health or safety thatwould require such action.
Monday, April 2

By morning the bubble was gone and the crisis at
TMI was over. Later, AP reporters placed a call toGeorge Troffer at the Met Ed news center. Troffer,believing the crisis was over, advised that the bubble had disappeared and no obstacles to cold shutdown existed. But, he retracted his statement when

he learned the NRC was upset with his announcement. After this, Troffer, with the concurrence ofFabian, closed down the news center because, for
all intents and purposes, there was no further needto "calm the public." 15
Just before noon Denton held a news conference
i n Middletown. He announced that the bubble had
been reduced in size enough so that it was nol onger considered a problem. Denton, however, did
not tell reporters the NRC had been wrong in its assumptions about the possible explosiveness of the
bubble. He said only that the staff had been very
conservative in their calculations. And, although the
emergency was over, the NRC continued to holdregularly scheduled news conferences for weeks
afterward, in order to keep the media informed ofrecovery developments.
Later in the day the NRC made technical staff
available in the news center to explain plant status
information to reporters. Members of the media
welcomed the presence of technical personnel (forthe first time), but were critical of the NRC for nothaving made them available sooner.
Still later, Hyde discussed Met Ed's communication problems with Met Ed officials. On April 4, thecompany retained the firm of Hill and Knowlton toreestablish good relations with their employees, thecommunity, and the news media.
3. THE CREDIBILITY ISSUEMet Ed's Saturday, March 31, announcement that
all future information on plant status would bepresented publicly by the NRC was rather anticlimactic. It was apparent by then that the utility
had lost its credibility with the news media and was
no longer considered a reliable source of information. This loss is best illustrated by the fact thatnone of the representatives from the two wire services or from the major television networks interviewed in this inquiry raised any objection to having
Met Ed virtually eliminated as a source of public information on the accident. It is further emphasized
by the fact that while only one media representative
we interviewed felt Met Ed deliberately held back information, the media in general felt that Met Ed wasunduly optimistic in the information it made public
and was, therefore, not a credible source. Media
representatives consistently used the term "downplayed" when describing Met Ed's presentation of
i nformation to the public, and intimated that, as information developed over the course of the accident, it became evident to them that Met Ed's earl y statements were overly optimistic. Reporters
106 8

discounted statements by the utility and sought
sources of information viewed as more credible,
usually the NRC. Some of the reasons why thenews media mistrusted the utility are listed here:• Met Ed continually discounted the seriousness ofradiation releases during the accident.

• The utility continually had to revise upward its estimate of core damage.

• The utility continually changed its mind as towhen cold shutdown could be achieved.

• Initial statements were made by the utility that noplant workers had been overexposed.

Other events which in the view of the media were
adverse to the credibility of Met Ed include:

• Lt.

•
•

•
•

Governor Scranton's statements at his
Wednesday afternoon news conference that Met
Ed had given the media and the State conflicting
information and that the situation was more complex than the utility first led the State to believe.
Herbein's remarks at Met Ed's Friday news
conference concerning the wastewater discharge
i nto the Susquehanna River.
Herbein's statements at the same press conference that Friday morning's release was controlled and planned, and measured 350 milliroentgens per hour, even though plant personnel
reportedly told State and NRC personnel that therelease was uncontrolled and measured 1200 milliroentgens per hour.
The perception that plant workers would not talkto reporters because of company directive.
The general unavailability of Met Ed spokespersons, both in Reading and at the observation
center, during the first few days of the accident.

Company officials who were involved in thedissemination of public information during the accident gave a variety of reasons why Met Ed wasn't
viewed as a credible source of information. The
reasons given include the following:• Because of poor physical communications, pri-marily phone lines, Met Ed was difficult to reachand was unable to return phone calls. This
created the impression that the utility was hidingfrom the press.
• Cognizant technical personnel, principally Herbein, were tied up with the accident and notavailable as company spokespersons.
• Met Ed could not obtain and give out complete
i nformation early in the accident because of therapidly changing status of the plant.
• A feeling prevailed among company officials thatthey had seen this type of transient before, fullrecovery had been achieved, and, therefore, thatwas what would happen again. This feeling led toan overly optimistic view of the accident during
the first day.
• The utility failed to notify the news media before
the Friday morning release of radioactivity-a
mistake that was compounded by Herbein's later
statements that the release was planned andcontrolled.
• The media believed that Met Ed would only tell
the truth when forced to do so, a belief based on
the delay in making information public.
• The press believed that Met Ed knew the planti nside and out and thus must have known exactly
what was going on at any time with respect tothe accident.
• The press overstated the conflicting statements
made by Met Ed and the NRC.
• The media perceived that because Met Ed had avested interest in the plant, they would not giveout negative information.
• Because security guards kept reporters awayfrom trailers where technical personnel were
working, the press felt that Met Ed wanted tooperate in secrecy.
The NRC, unlike Met Ed, was not as severely criticized by the media for one primary reason-Harold
Denton. While media representatives we interviewed gave Denton high marks, they generally criticized the NRC Headquarters. Reporters were particularly critical of the NRC delay in providing onsite
spokespersons and technical advisors. Some of thecomments are as follows:• The public relations official in a recently released

movie, The China Syndrome, conveyed a negative impression.
• Local news stories prior to the accident
described a serious hypothetical accident.
• The news media was left with the impression that
Met Ed knew all along that the accident was ofmuch greater magnitude but wasn't telling the
public when, after Met Ed issued optimistic statements on Thursday, the situation worsened on
Friday.
• Herbein's statement on Friday that, "I don't see
why we need to tell you each and everythingthat we do," alienated the media.

• The NRC should have had a technical briefer
available on site immediately, not 6 days after theaccident.
• The NRC got involved with the media on site too
l ate.
• Prior to Denton's arrival on site, the NRC's visibility was too low, probably because the NRC did1069

not recognize the seriousness of the accident
early enough.

Other
comments
concerningthe
Headquarters' performance are as follows:

NRC• The NRC Commissioners were more concernedwith looking good and protecting the industry
than in assuring public safety.
• The NRC Commissioners had no real concept ofwhat the news media people were doing at TMI;
their one thought, apparently, was that the press
was against them.
• It was obvious that the NRC and its public relations staff had given no advance thought to how
to handle the news media in the event of a major
accident. The NRC was not equipped to handle
TMI.
• The NRC's communications among its Headquarters, onsite personnel, and the King of Prussia office were poor.
• I nformation coming from the NRC Headquarters
was possibly too conservative. Headquarters
should have let Denton act as sole spokesman
because he was more familiar with plant status.

Typical impressions of Harold Denton as conveyed by news media representatives we interviewed included the following:• Our team placed more trust in Denton than Her••••

bein. Denton was more responsive, more in control, and more communicative.
Denton was accessible and informally gave out
i nformation to reporters when requested to doso.
We never got the impression that Denton was
giving out misinformation.
Denton did a good job of appearing to take command when he arrived on site Friday.
We were initially suspicious of Denton because
he was not known, but he quickly established his
credibility, credibility helped by the fact that
Governor Thornburgh showed a good deal offaith in Denton.

4. THE MULTIPLE NEWS SOURCESThe TMI accident was one of the major news
stories of 1979. As many as 400 news people
covered the story in the TMI and Harrisburg areas,
while another group worked at the White House andat the NRC in Washington. Their reports and commentary impacted directly and immediately on theli ves of three quarters of a million people living near
the reactor at TMI. For those outside the area,
107 0

throughout the Nation and the world, the accident
was perceived as life threatening to those near theplant, and held serious implications about the safetyof nuclear power reactors. For the utility, the State,
the NRC, and the media, it was a difficult story totell. It was a "first," and the accident continued fordays. The words and actions of the participants asreported by the media scared many of the people
around TMI, made the management of response to
the accident more difficult, and raised the level ofanxiety about the future of nuclear power.
Each of the participants recognized the responsibility to meet the public's right to know. Met Ed
President Walter Creitz said it was a long standing
company policy "to communicate openly and completely with our various publics." 16 Creitz added thatduring the accident Met Ed tried to tell the public aswell as the State and the NRC about "significant
events as they occurred." 17 I n fact, Met Ed's emergency plan calls for the station superintendent, in
conjunction with the Commonwealth of Pennsylvania, to make a decision concerning notification tothe "general public that an abnormal operating condition exists at the TMI nuclear station." 18 The
NRC's policy was likewise designed to ensure thatthe public would be kept informed of actual and potential hazards to health and safety. Moreover, it
was the NRC's policy to encourage "the licensee totake the lead in information activities
related to the19
accident occurring at their facilities."
This task was further defined in Region I's Incident Response Plan by instructions to the Public
Affairs Office to request the licensee to release information regarding the incident, "its cause, effect,consequences, injuries involved, action being taken,
20
etc. "The Governor, who had ultimate responsibility for the health and safety of the people aroundthe plant, also felt it important to apprise "the public
i n an event like this, which is so unprecedented, of
every bit of factual material there is." 21 Thornburgh
told the Hart Subcommittee that the State regarded
the public credibility of the Governor's office as
essential to the effort to avoid panic as well as toi mplement, if necessary, an orderly evacuation.
I n carrying out their public information policies,
Met Ed, the State, and the NRC failed to coordinate
public information to such a degree that the public
was unnecessarily confused and alarmed. The main
culprits were Met Ed and the NRC, but the Statewas not blameless. The first instance was conflicting information coming from within Met Ed itself, andl ater between Met Ed and the NRC during the first 2
days of the accident. These reports pertained to
the levels and source of radiation. This conflict led
first to Lt. Governor Scranton's public charge that

Met Ed was providing conflicting information to theState and the media, and finally to Met Ed's virtual
loss of credibility with the media and the public. The
second major example was the conflict between
Met Ed and the NRC Headquarters over the hydrogen bubble in the reactor vessel dome. The failure
to coordinate information on this subject resulted in
the silencing of multiple sources in favor of a single
voice speaking on plant status. The media acquiesced to this restriction.
During the first day of the accident, the main concern of the public around TMI was possible radiation
exposures from the plant. Initially, the worry was
not over how much radiation there was, but whether
there was any at all. The conflicting reports issued
by Met Ed and the NRC, and repeated by the Stateduring the course of the first 2 days, led to confusion and mistrust. The problem was compounded
further by the use of different terms in describing
the level of radiation monitored, by the various explanations of how it got out to the atmosphere, andby the disagreements on what it all meant to thehealth and safety of the public. Met Ed's first statement, at 7:30 a.m. Wednesday, made no mention ofa "General Emergency" to signify potential offsite
radiation. Met Ed's second statement said that "noexternal radioactive releases" had been found andthat "none were expected." 22 The NRC's firststatement, at 10:30 a.m., said that there had been arelease of radioactivity inside the reactor containment and that measurements to determine offsite
releases were being taken. At his first press conference, at 10:55 a.m., Lt. Governor Scranton said
there was a "small release of radiation to the environment," 23 but that he couldn't say how muchbecause it was not detectable in the atmosphere.
BRP's William Dornsife described the level as being
l ess than 1 milliroentgen per hour. At noon, Met Ed
told the public there had been "no recording of any
significant levels of radiation and none are expected
outside the plant." Herbein, in an impromptu press
conference shortly after 1:00 p.m., said radiation at
the site boundary was being monitored and was "a24tenth of the general emergency level."
Around
3:00 p.m. Creitz said radiation readings at the plantboundary were around 2 to 3 milliroentgens perhour. At 4:30 p.m., during his second press conference, Scranton announced:
The company has informed us that from about 11:00
a.m. until 1:30 p.m., TMI discharged into the air,steam that contained detectable amounts of radiation. The discharge was a part of the normal reactor emergency cooling process. It was done to relieve potentially dangerous pressure in the reactor
chamber. Because of an apparent leak in the pri107 1

mary cooling system, radioactive material wasdischarged into the air along with the steam.
Pennsylvania's DER was not notified of the releases
until about the time it was halted. The company
has said that further discharges may be necessary
25
and has promised to notify us in that event.
It was at this press conference that Scranton told
the media that "Met Ed has given you and us conflicting information," and that the situation was"more complex than the company first led us to believe." 26 Scranton added in response to a questionon whether he was being misled by Met Ed: "I think
there is a great deal of disappointment from our sidethat the company did not tell us that they wereventing radioactivity, particularly when statements
were represented that they made, that they said
there was no radioactivity being put out in the atmosphere." 27 The reporters at the site were beginningto show their instinctive distrust of the utility by asking whether the Lt. Governor was depending solely
on what the utility told him. As discussed earlier inthis report, Scranton's irritation stemmed from Met
Ed's failure to volunteer information on the so-called"steam dump" that was suspected to have contained radioactivity but in fact did not. It is ironicthat this act of caution initiated the slide of Met Ed's
credibility.
The first conflicting reports between Met Ed andthe NRC came with the Wednesday, 5:00 p.m., NRC
press release that stated that low levels of radiation
had been measured off site, levels principally attributed to direct radiation coming from the containment building. NRC press spokesman Fouchard
went on to say, "the accident sent radiation beami ng up to a mile away through the 4-foot-thick wallsof the power plant." 28 He cautioned, however, thatthe amount of radiation was relatively small. Additionally, Edson Case, Denton's deputy, said the radiation level inside the containment building was 1000
times normal, but when a reporter checked with Met
Ed's George Troffer, he was told that the 1000 figure was too high and that the level was perhaps 10times normal. At the Lt. Governor's third press
conference, at 10:30 p.m., he cleared up the confusion on the source of releases by describing what
he had reported to the Governor based on briefings
from NRC inspectors Higgins and Gallina:
There is currently no radioactive leakage from theprimary building or the reactor itself, there is radioactive material currently in the auxiliary building
which is being ventilated and, due to that ventilation, there is some dispersion into the atmosphere.
There have not been, and they have taken samples,
any critical levels found offsite. There are high, but
not yet critical, levels found onsite. 29

By midnight, NRC Headquarters caught up withthe situation and in its press statement said thereleases to the atmosphere resulted from water
pumped over from the containment building and lyi ng on the floor of the auxiliary building.
Herbein, in his CBS appearance on Thursday
morning, took slight issue with the NRC statement
about radiation levels in the containment and said
that at least one monitor may have been giving erroneous readings. He further stated that actions
were being taken to reduce the radiation from thewater on the auxiliary building floor. Another probl em grew out of the NRC Headquarters' briefing of
the Hart Subcommittee, a briefing which indicatedhuman error was involved in the accident. Herbein
took exception, saying human error had yet to beestablished. The NRC inspectors on site supported
Herbein and said, "preliminary evaluation indicated30
By Thursday night
no operator error occurred."
the people around the plant were confused. Governor Thornburgh, in his first press conference, took
note of the conflicting reports:

I realize that you are being subjected to a conflicting array of information from a wide variety ofsources. So am I. I spent virtually the entire 36
hours trying to separate fact from fiction about thissituation. I feel that we have succeeded on the
more important questions.

By this time the populace was confused bystrange sounding terms: releases, emissions, venti ng, ventilation, millirems, paths of leaking radiation,site emergency, and general emergency. On Friday
morning the populace was exposed to a more disturbing set of words: unplanned and uncontrolled
releases or emissions. Around 9:45 a.m. Paul
Critchlow, referring to Thornburgh's conversation
with Chairman Hendrie, told the press that there had
been an unplanned and uncontrolled burst of 1200
milliroentgens per hour above the the TMI-2 stack.
Herbein, in his 11:00 a.m. press conference, said therelease was not uncontrolled, as stated by the NRC,
but was made on purpose, in order to relieve pressure in an effort to reduce contamination danger.
He insisted he understood the release measured
350, not 1200, milliroentgens per hour. At theGovernor's noon press conference, Gerusky said he
was told by Met Ed prior to 8:00 a.m. that they had
had an uncontrolled, unplanned release of radioactive material. Met Ed's credibility dropped to nearzero as the media began to view Met Ed's statements with a jaundiced eye. In an accident situation, the public is certain to view any utility statements as self-serving, but Met Ed compounded their
credibility problems by being overly optimistic andby downplaying radiation data.
On Friday afternoon, the NRC opened its press

center in the East-West Towers in Bethesda. The
purpose of the center was to make technical advisors available to assist reporters in understanding
the technical situation at the TMI plant. It was thiscenter and its link with the Incident Response
Center that created major problems for the State ofPennsylvania. Thornburgh, appearing before thePresident's Commission on August 21, singled out
two news events which made his task more difficult.
He cited "a report on Friday afternoon, relating to asupposed imminence of a meltdown and a report on
Saturday evening relating to supposed incidence ofan explosion."32 Both of these stories, he said, wereat best distorted and caused a good deal of concern among the general public. A special effort was
required by the Governor and by Harold Denton at
the site to put to rest the alarming nature of thesestories. Chairman Hendrie, in a press conference
on Saturday afternoon, added to the Governor's
problems by mentioning the possible need for a
20-mile evacuation radius. This jumped the affected public from 136 000 to over 600 000 people, andthe phones rang off their hooks in government offices in Pennsylvania.
Each time such a story hit the streets,
Thornburgh's aides called the White House to checktheir accuracy as well as to note their adverse impact on the State's attempts to manage the emergency. This, in turn, triggered a series of calls
among White House officials, the NRC officials at
the site, and the NRC Headquarters. Eventually, thepress center at East-West Towers in Bethesda wasclosed down, and it was announced that an NRC
press center would be opened in Middletown. Early
Saturday morning Met Ed had announced it would
no longer hold press conferences and that the NRC
would henceforth speak for plant status. At this final press conference, Herbein said the hydrogen
bubble had been reduced to two-thirds of its Friday
size, and stated that the crisis was over. Denton
took issue immediately, and said the crisis was notover and would not be over until cold shutdown had
been achieved. Denton would not accept Met Ed's
figures on bubble size. Throughout Saturday afternoon Met Ed's news center in Hershey continued torespond to questions about the size of the bubble,
and took issue with the view of the NRC office in
Bethesda on the possibility of an explosion. Laterthat evening Jack Watson called Herman Dieckamp
and discussed the problem of conflicting reports.
Met Ed then instructed its news center to refer allquestions on plant status to the NRC and to limit its
responses to background information on TMI.
Early on in the accident Pennsylvania's BRP had
referred all press queries to DER. By Friday, PEMA
and DER had deferred to the Governor's Press
107 2

Secretary. On Friday, Jody Powell in the WhiteHouse had assumed responsibility for all press
statements concerning Federal emergency support
to Pennsylvania. With the events of Saturday, public sources of information had been reduced to Denton for information on plant status, Powell for
Federal emergency assistance, and Thornburgh forevacuation and emergency response. No one, however, provided details on radiation monitoringaround the plant. At the time, the press accepted
the limitation on news sources, but since has questioned the wisdom of accepting such limitations.
Met Ed did not provide full and complete information at the outset, but Met Ed spokespersons did
not have all the facts at the time. The NRC did not,early on, assure that Met Ed provided complete information and, by refusing to work with Met Ed in
the public information area, contributed to the conflicting reports. Abraham rebuffed Met Ed's invitation to participate in a press conference. Denton
refused an offer from Creitz to issue a ioint press
statement on plant status on Friday afternoon. To
preserve his credibility, Thornburgh refused to haveany contact with Met Ed. There were good reasonsfor the standoff posture of the NRC and the State,
but as a result of the extent of their posture,
cooperation was inhibited and distrust resulted.
One other aspect of this overall problem should
be noted. Late Wednesday night NRC Inspector
Gallina was asked by a reporter what would happen
if the core did not cool off. He responded, "That is
not the situation we have here and I prefer not tohypothesize for what we don't really have."33
Whether he was aware of it or not, Gallina at theti me was following the Region I guidance: "Avoid
speculation! The spokesman should avoid commenting on hypothetical situations. Answering what
would have happened if ... questions tends to aid
misunderstanding." 34 The hydrogen bubble scare,i nvolving the possibility of a meltdown as well as an
explosion, was created by the NRC because it failed
to adhere to that guidance.

event. Other reasons include: poor communications, the existence of multiple sources of information, and the fact that spokespersons often did
not receive accurate, up-to-date information fromtheir respective organizations. The problem wasfurther compounded by the NRC's refusal, after
Harold Denton's team arrived on site Friday, towork with Met Ed in trying to provide a single,
credible account of the reactor's status and of
potential dangers to the public. The State, which
relied upon Met Ed and the NRC for its information, could only report what it was told. We did
not develop evidence to establish that any ofthese parties willfully provided false information
to the media during the accident.
Findings-Metropolitan Edison• During the first 2 days of the accident, Met Ed
consistently emphasized optimistic aspects of thesituation and avoided any statements it feared
might alarm or panic the public. Moreover, Met
Ed spokesmen demonstrated a reluctance toprovide the public with detailed information on radiation releases. However, we found that Met Ed
spokesmen themselves were not aware of theseriousness of the accident during those first 2
days and that they did not willfully distort the information available to them in order to mislead
the press. After the first 2 days, Met Ed consistently provided accurate information to themedia, but by that time the company's credibility
had been destroyed.
• The sporadic accessibility of onsite Met Ed officials to the news media, the rapidly changing andworsening events of the accident, and the limited
i nformation available to Met Ed spokespersons
early in the accident all contributed to the utility's
i nability to provide full and complete informationon the accident.
• The limited public relations experience of Met Ed
principal spokesman Jack Herbein, compoundedby the limited nuclear background of reporters
covering the story, adversely affected the flow ofi nformation between the utility and the media.
• Met Ed's public information office was not adequately staffed nor was it prepared to effectively
i nterface with the news media during the TMI accident.

5. SUMMARY OF FINDINGS AND
RECOMMENDATIONSGeneral Findings. Information provided to the news media by Met
Ed, the NRC, and in some cases the State during
the accident was often incomplete, untimely, or
i naccurate. We found that these failures werecaused primarily by the lack of preparation on
the part of Met Ed and the NRC to be ready toi nform the media adequately in this kind of an

Findings-NRC• NRC public affairs planning did not take into ac-

count the likelihood of an accident of the typethat occurred at TMI-2 and that, as a result, the
NRC was not prepared to property interface with
the news media during the course of the accident.

107 3

• The NRC sent too few personnel to the TMI site
to obtain and provide the information needed by
the NRC's offsite spokespersons. This problem
was further compounded by the inadequacy ofthe existing telephone system.
• Confusion created by conflicting statements
between the NRC spokespersons at Headquarters in the Washington, D.C., area and those near
the site was partially attributable to a tendency
on the part of Headquarters spokespersons torelease information without awaiting confirmation.
• The NRC demonstrated a willingness to specul ate on possible developments and to answer"what if" questions, a willingness that resulted inagency staff contributing to several alarming reports during the accident.
• There was no advance planning for a local facility
where the NRC could expeditiously establish an
onsite news center able to deal with large
numbers of reporters. Such a facility was needed at the onset of the accident.
• The NRC erred significantly in not providing thenews media with a technical briefer on site until 6days after the accident began.
• Reporters' understanding of matters discussed at
the NRC press briefings was hampered by thelack of basic information on radiation releases
and protection and on reactor design and operation.
• Overall, Harold Denton, the NRC's principal
spokesman, was found by the media to be
responsive, credible, and reassuring, but at times
he lapsed into technical jargon that was difficult
for lay people to understand. In retrospect, Denton, due to erroneous staff input, did not provide
the media with completely accurate informationon the analyses associated with the hydrogen
bubble.
• The NRC waited too long to issue its initial publicannouncement on the first day of the accident
and did not issue announcements frequently
enough thereafter to keep the media fully andproperly informed.
• NRC announcements were also not as informative as they should have been; some lacked clarity because the NRC did not discuss the significance of the information reported (especially withrespect to radiation releases). Too, the NRC did
not indicate the source of all reported information
or explain that information might change overti me as a result either of new developments or investigation by the NRC.
• Delays in issuing public announcements appeared to be attributable, in part, to an unnecessary and time-consuming process of obtaining

concurrences from both of the staff offices aswell as the Commissioners.
. The Public Affairs Office did not have adequate
staff to properly work with the media nor did it
have adequate technical personnel to provide explanations on the radiological and operational aspects of the accident. This situation resulted in
distracting phone calls to the technical staff in the
I ncident Response Center.
Findings-The State of Pennsylvania• The State of Pennsylvania did a commendable
job under trying circumstances in providing credible information to the public about the TMI accident and about potential hazards to publichealth and safety. The State, as a result, minimi zed panic and ensured that the implementationof emergency action, if necessary, could havebeen carried out with a minimum of confusion.
• The State of Pennsylvania exerted subtle pressure on the White House and the NRC to elimi nate many of the separate sources of information available to the news media. This approach
served the State very well by reducing confusion
and the level of anxiety, but, in hindsight, few
people thought it was a good idea to restrict the
public's right to know in this fashion.
Recommendations• All utilities operating nuclear powerplants should

designate a place equipped to serve as a communications center in the event of an accident
that requires extensive work with the news
media. Such a facility must be near the site.
• A senior NRC official on site or near the siteshould be the principal spokesperson at press
conferences during an accident at a nuclear
plant. A utility spokesperson should be present
at such press conferences to provide any differi ng views or additional information the utility feels
i s necessary to keep the public properly informed. A cognizant State official also should bepresent at these press conferences and shouldhave sole jurisdiction for public information concerning evacuation and related planning. The
utility should still maintain responsibility for initialpublic statements until the NRC can establish an
onsite or near-site capability for media interface.
Press briefings should be held at least three
ti mes a day, depending on the situation.
• Each utility operating nuclear powerplants should
ensure that a member of its public relations staff
has extensive experience in dealing with the local
media and that he or she has a detailed under107 4

•

•

•

•

standing of the operating and radiological aspects of the utility's reactor plants and can participate effectively at the press conferences.
Each utility operating nuclear powerplants should
prepare a standard briefing package, for eachplant, which provides background information
about the plant and which can be disseminated tothe media as required. This briefing package
should be approved by the NRC, and the NRC
should have verbatim copies at Headquarters andat regional offices for emergency response purposes.
The NRC should establish requirements that will
ensure prompt notification of the news media
when a nuclear facility experiences an event that
could impact on the public's health and safety.
Such requirements should ensure that this early
notification is made by an informed individual.
The NRC nuclear accident response teams
should include at least two technical individuals,
one with a background in health physics and theother in reactor design and operations. The primary mission of these two would be to gather
onsite information concerning the cause of theaccident, to monitor the changing status of theplant, to assess the radiological risk to the public,
and to communicate this information to the NRC
public affairs staff and spokespersons, who could
then keep the media fully and currently informed.
Another response team member should be designated to establish and maintain open channels ofcommunication to offsite centers involved inmedia interface activities. The NRC Headquarters should designate specific personnel to communicate with their onsite counterparts for purposes of exchanging information.
The NRC should choose and train members of
the technical staff to serve as technical advisors
to the media following any future nuclear accident. This staff should be chosen in part because of their technical knowledge of particularlicensed operations and in part because of theirability to effectively communicate technical concepts to a lay audience. No calls from the media
should be taken by or referred to members of thestaff involved in managing the NRC's emergency
response activities.
• The NRC should develop a standard format forpress releases to ensure inclusion of basic information concerning a nuclear accident: dates,
ti mes, radiation levels, and type of accident.
Press releases should also include the source of
the information (the NRC official, State official,licensee spokesperson) and should clearly indicate that the events described therein are subject to change with the passage of time. This
format should be accompanied by example press
releases written in lay terms. This information
should be made available to all utilities operating
nuclear powerplants.
• The NRC should establish a clear policy of issui ng prompt public announcements concerning nuclear accidents. Such a policy should includedelegation of responsibility to the Director of the
Office of Public Affairs for issuing press releases
without the concurrence of any NRC Commissioner. Concurrence should only be obtained
from the cognizant licensing office.
• The NRC should take the lead in working withresponsible State agencies to develop a public
information program to educate the general public (and more importantly the populace in the immediate area of an operating reactor) on nuclear
power and its consequences. Such a program
should include information on reactor operationand the potential hazards of radiation both in thecase of normal operation and in the event of an
accident. In conjunction with establishing these
programs, the NRC should develop simplified
literature on the subjects and disseminate thisliterature to State and local agencies.

107 5

REFERENCES AND NOTES
Fabian Interview Memo (August 28,1979) at 2.
2
Transcript of telephone conversation between G. P.
Miller and G. Troffer, March 28, 1979 at 1-5.
3Public statement by Met Ed, March 28, 1979, 12:00
noon.

20

U.S. Nuclear Regulatory Commission, Region I
I ncident Response Plan, Appendix D, at I.
21
Thornburgh dep. at 47 (Pres. Com.).
22
Public statement by Met Ed, March 28, 1979, 10:00
a.m.

1

Hq. IRC Day 1 Transcript 01-135-CH4/22-WH-2.
5
Transcript of Met Ed press conference, March 17,
1979 at 14.
6Transcript of Met Ed press conference, March 30,
1979 at 6.
7
Creitz dep. at 36-40.
8Transcript of Met Ed press conference, March 31,
1979 at 4.
9
Transcript of Met Ed press conference, March 31,
1979 at 5-6.
10
Hq. IRC Day 4 Transcript 04-768-CH17/203C-DC-6.
'"Memo from J. Watson, White House Aide, to the
President, Subject Status Report - Three Mile Island
Nuclear Facility, Report #3, dated March 31,1979.
12
Dieckamp dep. at 43-44.
13
Transcript of State press conference, Part 1, March
31,1979,11:00 p.m. at 6.
14" Crisis: Three Mile Island," Chapter 10, p. 2, The
Washington Post, (undated).
15
Troffer Interview Memo at 6.
18
Creitz dep. at 5 (Pres. Com.).
Vid.
4

Ed Emergency Plan, Section 5.5, at 12A-10.
U.S.
Nuclear Regulatory Commission
Manual,Chapter 0502, "NRC Incident Response Program," Sec.
8b., at 4.

23

Transcript of March 28, 1979, 10:55 am., State
press conference at 1.
24
Herbein Interview on May 10, 1979 (I E) at 9.
25
Transcript of State press conference, March 28,
1979, 4:30 p.m. at 1-2.
28 Transcript of State press conference, March 28,
1979, 4:30 p.m. at 1.
27
Transcript of State press conference, Part 2, March
28,1979, 4:30 p.m. at 6A.
28
AP Wire Service release, Time 12:25 am., dated
March 29,1979.
29Transcript of State press conference, March 28,
1979, 10:00 p.m. at 1.
30 Transcript of State press conference, March 29,
1979,10:20 p.m. at 6.
3'Transcript of State press conference, March 29,
1979,10:20 p.m. at 1. _32
Thomburgh dep. at 45 (Pres. Com.).
33
Transcript of State press conference, March 28,
1979, 10:00 p.m. at 9.
34
U.S. Nuclear Regulatory Commission, Region I
Incident Response Plan, Appendix D at 2.

*

107 6

APPENDIX 111.1

BACKGROUND ON NRC PLANNING
FOR EMERGENCY RESPONSE

Summary
Before the accident at TMI the NRC's perceptionof its role as an agency in connection with emergency response to a serious nuclear accident at a
power reactor was a rather ambiguous third partyrole-one of backup support to primary roles playedby the licensee and State and local emergency authorities, with some vague sense of the need to dosomething if the licensee failed in its primary role.
There was also a role of coordinating response
actions of other Federal agencies in bringing
Federal resources to bear in the State's responseto an emergency. Section III.C of Volume II and
NUREG/CR-1225 (entitled "Major Alternatives for
Government Policies, Organizational Structures, andActions in Civilian Nuclear Reactor Emergency
Management in the United States"), as well as the"Report on Emergency Preparedness by the Officeof the General Counsel of the President's Commission on Three Mile Island," among other studies, discuss this role and its background. This reportfocuses on the NRC's emergency response planningin relation to the licensee and the State.
It is difficult to identify a specific basis for thisthird party perception by the NRC, because little inmaterials that discuss emergency response to aserious nuclear accident deals explicitly with specific functions that should be carried out by the NRC.
However, from those that do, there appears a constellation of separate but related concepts that together tend to suggest little need for an active NRC
response role in nuclear emergencies. Apparently,
these concepts contributed to the ambiguous statusthat characterized the NRC plans for its own participation in emergency response. These plans, while
overflowing with objectives, did not come to grips
with necessary organizational structure and related
communications needs that would enable the agency to achieve its objectives under accident conditions involving significant uncertainty about the nature of the damage, about the ongoing risk, andabout the character and adequacy of actions taken
in response to the accident.

107 7

1. BACKGROUND

the issuance of an immediate order to enter andoperate a facility in order to shut it down and render
it safe while the APA notice and hearings on the revocation are completed. A condition precedent tosuch action is an immediately effective revocation of
the applicable licenses.
The existence of these sections dealing explicitlywith certain circumstances does not detract fromthe application by the Commission of other broad
regulatory authority in emergency situations; that is,
the NRC may use any other regulatory authority it
has in an emergency situation, including section 161i,
which grants the power to "prescribe such ...orders
as it may deem necessary... to govern any activity
authorized pursuant to this Act... protect health andminimize danger...."
Although the Act provides the Commission withbroad, nonspecific regulatory authority to impose
requirements on licensees to protect health andsafety and to minimize danger (103,161i, 161b, etc.),
the statute does not impose on the Commission an
obligation to take any specific role or action in theevent of a serious accident; nor, on the other hand,does the statute restrict the role the Commission
may play in exercising its broad regulatory powers
over the licensee. 5
The Act does not provide the NRC with authority
to use police powers in the vicinity of private nuclear power reactors. Thus, to the extent that poli ce powers are required to effect needed offsite
protective measures in the event of an emergency,
participation by State or local authorities vested with
police power will be essential. Although this leads
to ascribing an important role to the States, it does
not restrict the NRC from taking an active, evendominant, role in assessing the danger posed by aserious nuclear accident, nor in determining theneed for specific actions and requesting State police power assistance. Though the statute could
define a clearer role for the NRC, the statute does
not limit the NRC's role, except to the extent thatthe actual exercise of any needed police powers
would require the participation of State and local
authorities.

a. Statutory Basis

The Atomic Energy Act s does not describe any
specific role for the NRC in the event of a serious
accident at a licensed nuclear powerplant; 2 nordoes there appear to have been any definitive legal
analysis of the statutory authority of the NRC inconnection with response to nuclear emergencies. 3
With respect to the regulatory activities that weretransferred to the NRC by the Energy Reorganization Act, the Atomic Energy Act is principally cast in
regulatory terms:• It imposes obligations on persons to "possess"facilities and materials in order to obtain alicense;• It i mposes obligations to obey the Act, theCommission's regulations, and the license;• It authorizes the Commission to issue licenses
and to impose standards and regulations governing "possession" of facilities and materials.

The Act deals with emergency situations explicitly in two instances in three sections. These sections are directed principally toward the recaptureby the Commission of facilities in order to continue
operation, rather than toward recapture for the purposes of safe shutdown.
Under Section 108, should the Congress declarea national emergency, the Commission can suspend
licenses, order recapture of special nuclear materials, order operation of the facility, and order entry tooperate. It is unclear whether this was intended toapply when the operation of the facility itself, or an
emergency at the facility, constituted the "national
emergency."
Under Section 188, in cases of license revocation, if the Commission finds that "public convenience and necessity" or production programs 4 require continued operation of the facility, the Commission may, after consulting with appropriate Stateregulatory agencies, order that the facility be takenover and operated. Under Section 186, in revocation cases involving operations of extreme importance to the national defense or to the health andsafety of the public, the Commission may recapture
and operate the facility even before completing administrative procedures provided under the Administrative Procedures Act (APA). It is unlikely that thiswas intended to apply if the facility became a threat
to health and safety; the only operations intended tobe performed by the NRC were those leading tosafe shutdown. Nevertheless, Section 186 appears
broad enough to encompass a condition of extreme
i mportance to public health and safety and permits

b. NRC Role Concepts
Rather than reflecting some statutory limitation,
apparently the NRC's view of its role in serious nuclear emergencies prior to the TMI accident wasshaped by, or at least corresponded to, certain concepts concerning the nature of potential nuclear accidents and the nature of responses needed in such
events. These concepts appeared to leave little of

107 8

value tnat couia De contnoutea ay a aistant organization not intimately familiar with the specific nuts
and bolts of the reactor in which the accident occurred.6
Limits on Accident Planning

Before the development of NUREG-0396, thebulk of the AEC-NRC expressions concerning
emergency planning was clearly directed toward
consideration only within the scope of large designbasis accidents. Although the consequences ofsuch accidents are significant, they are limited rather sharply by the design of the plant and would provide a known upper bound to the severity of theaccident-a bound of fairly local immediate impact.$
There were indications in some nuclear emergency
planning documents that emergency plans should
cover a range of incidents up to events involving
severe damage and widespread contamination.
These generally were contained in documents maki ng overall recommendations that there be disasterplanning covering a wide range of incidents andevents, including sabotage, weapons events, andreactor and materials accidents. NUREG-0396
states on page 111-4: "NRC and other Federal agency
planning guidance has perhaps been misinterpreted
as reflecting a position that no consideration should
be given to so-called Class 9 accidents for emergency planning purposes."This misunderstanding is natural in light of thel ow profile given to reactor accidents in the broad
emergency planning guidance in the documents cited by NUREG-0396 9 when contrasted to the em10
The same
phasis given to design basis accidents.
i s true concerning the heavy emphasis in NRC regul atory guidance on planning for
11 the limited area ofthe low population zone (LPZ).
In recent years, since the draft promulgation of
EPA's Protective Action Guides (PAGs) at levels
substantially lower than the values set forth in 10
C.F.R. Part 100, 12 the guidance that limits planningconsideration to the LPZ has been under revision.
More recent guidance has suggested that planningshould be extended beyond the LPZ. In general,though, this guidance seemed clearly related to providing protection for projected exposures down to
the PAG levels rather than protecting against ac13
cidents more severe than design basis accidents.
The attitude of excluding accidents larger thandesign basis accidents began to shift after theReactor Safety Study, WASH-1400. With thedevelopment of NUREG-0396, the NRC provided
explicit consideration of planning for accidents more
severe than design basis accidents. It did not, how-ever, except for specifying two planning zones (oneout to 10 miles and one out to 50 miles), come togrips with the implication of this guidance on detailsof planning,14 nor did it come to grips with the broad
i mplications in studies showing a range of core melt
accident probabilities with very high radiation
15 doses
substantially beyond 10 miles from the plant.
The Commission's recent Statement of Policy
adopting the 10-mile airborne emergency planning
16
zone and the 50-mile zone for contaminated foods
also skirts the inconsistency implicit in its acceptance of a 10-mile planning zone, and, at the sametime, stating as a policy that emergency plans
should take into consideration "a spectrum ofdesign basis and core melt accidents." NUREG
0396,
the
document
referencedbytheCommission's policy statement, shows a specificportion of the spectrum of core melt accidents(some 30% on Figure 1-11, 10% on Figure 1-15, and
90% on Figure 1-16), with whole-body doses in excess of 5 rem at 10 miles. Figure 1-15 shows highdoses for substantial distances beyond 10 miles forsome portion of the spectrum of core melt accidents. For probability values at the traditional-6
per reactor year level, 17"one in a million" or 10
doses in excess of 50 rem whole body are shown in
Figure 1-15 beyond 30 miles.
It may be that the estimates of large distances
18
must be used with caution, but the implications ofthese estimates deserve more consideration than
the assertion in the Commission's policy statementthat the 10-mile airborne exposure and the 50-mile
contaminated food zone distances "are consideredlarge enough to provide a response base which
would support activity outside the planning zone
should this ever be needed."
Accident Types Considered

Although there is some mention of the potential
for slowly developing accident sequences, 19 a large
number of accident discussions in pre-TMI material
concentrate on short accident sequences, 20 thosewhich impose the most strain on communications
and on State and local response resources. Related to this concept of short accident sequences was
the emphasis on dealing with well defined events ofreadily identified characteristics-and lack of consideration of uncertainties. 21 I n the main, the situations discussed in various background documents
dealt with well defined events 22 or suggested thatthe nature of the accident
events can and will be
23
identified rather promptly.
The concentration on these short accident
scenarios and rapid decisionmaking emphasized the107 9need for close coordination between the licensee,
who has the most direct knowledge of plant conditions, and local authorities, who may have to undertake prompt protective measures. 24 This, in turn,relegated the NRC-a distant agency-to a secondary role. Although it may
be an important support
25
role, it is still secondary.
Reliance on Licensees

The NRC's perception of its role in responding toa serious accident at a licensed nuclear reactor was
based on the concept that the plant operating organization has great technical competence combined with an intimate knowledge of the design, layout, and operational idiosyncrasies of its plant. This
combination would put the licensee in the best position to judge the choice and usefulness of whateveractions could or should be taken in dealing with anaccident or unstable condition that results fromtransients, failures, or errors during operations. 26
I n such circumstances, persons or organizations
with a more remote ability, which may be very usefuli n performing an advisory function, may very wellhesitate to intervene in the "hands-on" response to
the accident. 27
Responsibility of States in Emergencies

Another concept which appears in various documents and which may have contributed to an NRCview of its role as "secondary," was one that expressed in jurisdictional terms that the "primary"
responsibility for responding to28emergencies is with
State and local governments.
This concept appeared to be accepted as a truism related to theStates' authority to regulate matters of public healthand safety. 29 However, it is not clear how these
traditional jurisdictional concepts are affected by the
nontraditional structure applicable to nuclear reactor
regulation in which there has been Federal preemption of regulatory authority with respect to radiological health and safety.
Both the Federal and State Governments haveimportant responsibilities in connection withresponse to a serious nuclear accident. Federal
agencies have primary regulatory authority over thebasic activities. The State is the principal source ofpolice powers that may be needed to carry out protective measures. But there appears to have been
little recognition of the importance of both of thesesets of responsibilities in connection with emergency response to a serious nuclear accident. Rather,
there was mainly only the overly simplified assertion
that, "the responsibility for protection of the public in

the environs [sic] a nuclear power plant rests with
the Governor of the state in which the plant isl ocated." 31
c. Experience
These concepts concerning the nature of nuclear
accidents and the responses needed in such eventswere not challenged seriously by accidents thattook place prior to TMI. Four will be used as
examples.
SL-1

On January 3, 1961, at 9:00 p.m., a serious nuclear accident occurred at a small military powerreactor at the AEC Idaho Testing Station. The accident involved a power excursion during planned
maintenance and work on the core. Three operators were killed. The Station was an AEC contract
operation, with substantial technical operating capability. The local AEC Health and Safety Division supervised overall health and safety activities at thesite. Promptly after the alarms were sounded, AEC
fire and security teams, with technical support fromvarious contractor personnel, undertook lifesaving
and radiological control. Events appeared to havestabilized sufficiently within 12 hours to permit reopening of a nearby highway, although there
remained some uncertainty over an extended periodof timeas to how to proceed with the recovery pro32
gram.
Although a Commissioner, the AEC's General
Manager, and other Headquarters officials were at
the site on the following day, overall operational
control was apparently exercised by the AEC Idaho
Operations Office; radiological control was carriedout by the local AEC Health and Safety Division.
The report of the AEC investigation into the accident
appears to be mildly critical of the early presence at
the accident site of so many outside officials andother personnel. 33
Fermi 1

At 3:10 p.m., October 5, 1966, there was an accident involving flow blockage by a loose piece ofzirconium plate resulting in the melting of two fuelelements. The reactor was scrammed on abnormal
i nstrument behavior about 10 minutes after initial indications of a problem. By 6:30 p.m., a meeting ofi mportant technical management and others withlong and close association with the development of
the design of the reactor was convened. 34 At the1080

meeting, it was concluded that all rods had been inserted, that there was no sodium leakage, and thatradiation leakage was local and confined; no additional measures were needed to protect public
safety.
The AEC was notified of the event after thismeeting and a local newspaper was informed. The
AEC inspector arrived the next day and concluded
that there was no hazard. 35 The AEC did not issue
a report on this event.
Browns FerryAt approximately 12:30 p.m., March 22, 1975, aworkman using a candle to test for leaks started an
extensive fire that damaged electrical control systems for both Units 1 and 2. Both units werescrammed within about 30 minutes, but the fire continued until about 7:45 p.m., resulting in the loss of anumber of Unit 1 decay heat cooling systems. The
local fire department was called at around 1:00 p.m.
and quickly responded. The licensee activated its
offsite emergency centers between 2:30 and 3:00
p.m., then notified the State and the NRC at around3:30 p.m. The fire was put out by about 7:45 p.m.
NRC inspectors arrived on site very late that night.
There was subsequent criticism of the licensee's
failure to use water on the fire earlier. A local fire
chief had recommended at about 2:00 p.m. andagain later that water be used, but nothing wasdone until around 7:00-7:20 p.m. There is no indication that the NRC made a recommendation to use
water, although there are indications that the NRC
communicated with the licensee's emergency
center. 38
Ft. St. Vrain

On January 23, 1978, at about 9:00 a.m., an instrument malfunction led to a release of primarycoolant helium to containment, a release containing
about 4 curies of noble gas fission products andabout 5 microcuries of iodine. The licensee initiallymisinterpreted the stack monitor as indicating all
iodine, and thus made a very large overestimate of
the off site doses. The plant was evacuated bynonessential personnel at approximately 10:00 a.m.,
and roads in the area were blocked. The county
and State were notified at about 10:15 a.m.; the NRC
at about 10:30 a.m. Radiological assistance teams
were notified at about 11:00 a.m., but were neverused. The releases from the primary system were
stopped by approximately 11:20 am., and personnel
returned to the plant at 2:30 p.m. NRC inspectors
arrived at 6:00 p.m. There is little indication of any
108 1

specific NRC recommendation for action by plant
operators. 37
d. Overall NRC Attitude Toward Emergency
Planning
Concepts derived from all of the above formed aframework for emergency response to nuclear accidents in which the following circumstances wereenvisioned:• An accident, if one should occur:a. would develop very rapidly,
b. would be readily diagnosed by the licensee,
andc. would have offsite consequences limited to
the vicinity near the reactor.
• The licensee would rapidly diagnose the eventand then would quickly and competently respondto the event, taking appropriate action to minimize offsite consequences. Browns Ferry raised
the spectre of a licensee not responding quickly
and correctly; however, the crisis stage of imminent danger was over within four hours after
the NRC was first notified and before any NRC
personnel reached the site.
• State and local authorities would be promptly informed. Protective actions, if any, would beneeded only in very limited areas.
Given this framework, it is not surprising that theconcept of emergency planning as a component ofadequate public health and safety protection did not
develop within the NRC. Rather, this component
was viewed as an "add-on," providing something
extra over the "adequate" safety provided by siting
features and design characteristics. 38
It is against this background that the NRC
developed its agency plans for response to nuclear
emergencies, plans characterized principally by ambiguity in the role to be performed by the NRC.
2. PLANNING FOR NRC RESPONSE TO
EMERGENCIES
a. 1975-1976 Initial Planning
GeneralThe initial
NRC plan for its role in emergency
39
response
was similar to the AEC plan forresponse to emergencies at non-AEC facilities.
Although the plan sets forth as an objective, "To assure that proper actions are taken to protect healthand safety... from the consequences of incidents

which occur as a result of NRC-licensed activities-.11 40 the plan did not come to grips with how
this was to be accomplished by the NRC-a distantregulatory body with little of the operational capability of the AEC and its contract organization, an organization that had been transferred to ERDA. Except for general directives to various officials on the
NRC staff to take appropriate action, 41 the principal
NRC emergency responses covered by the initial incident response plan were to gather information,
notify others within the agency and outside the
NRC, request assistance from ERDA, and coordinate Federal and State agency actions. 42 In addition, the plan mentioned certain planning activities
and after-incident investigations and measures toprevent recurrences. 43
The plan identified no role for the Commission,and limited the role of the Executive Director forOperations (EDO) to determining whether an event
should be reviewed by a special incident review
committee chaired by the EDO's Technical Assistant. 44 I ndeed, the entire response function was
vested in the Director of IE and an Incident
Response Action Coordination Team (IRACT), 45 i ncooperation with the Regional Office. 46 The Directors of NRR and NMSS, in addition to having a general duty to provide staff for IRACT' 47 were assigned responsibility48 for imposing notification requirements on licensees, for seeing to the preparation of after-incident reports to determine if additional safety evaluations or changes were needed,
and for after-incident calculations of "corrective actions proposed by the licensee as a result of the incident."
The NRC incident response plan was implemented by IE Manual Chapter 1300. 49 This Manual
Chapter went into greater detail on specifics regardi ng the actions of IE and the Regional Offices in
response to emergencies.
The IE plan called for the IRACT (under the
Director of IE, assisted by the Deputy Director and
IE Division Directors) to coordinate the IE Headquarters and Regional Office responses. The plan further provided that IRACT was to be supported by"staff members" from NRR, RES, NMSS, etc., but did
not ascribe to particular offices any specificresponse. 50 It provided guidance on the initial information to be obtained and the initial notifications to
be made,51 although specific phone lists were noti ncluded in the IE Manual.
The plan provided general guidance concerning
public information activities. Though NRC press
releases were to be made in certain instances,licensees were encouraged to take the lead. It required that NRC press releases "be factual andmust report accurately the licensee's position orstatements about the incident" as well as provide "a52statement of actions taken by NRC ...."The IE
Manual repeated this guidance for Regional Directors, but went on to identify the types of 53
incidents
for which press releases should be issued.
The IE Manual also called for Regional Office
response under the direction of the Regional OfficeDirector. 54 It provided guidance for classifying incidents on the basis of severity, directives to notify
Headquarters promptly and to dispatch an inspector
or team to the scene of serious (Level I or II) events,
guidance regarding the information to be obtainedby the Onsite Team, and guidance on regional notification of other Federal agencies 55 although, again,
specific phone lists were not included.
The overall organizational structure under the initial plan was rather straightforward. All response
action functions were vested in the Director of IE
and an IRACT composed of the IE Director, Deputy
Director, and Division Directors. Similarly, the regional response was to be carried out under the Regional Director.
Function of the NRC Response

While the organization was straightforward, theplans provided no sense of what, if anything, the
NRC was to do in the event of an accident, otherthan to gather information and notify a number of
persons and organizations. For security threats, theplan was fairly explicit: the FBI had lead responsibility, with the NRC gathering information, notifying
the FBI, and, along with ERDA, providing
technical
56
assessment and other assistance.
For operational incidents, the initial plan statedthat the NRC's objective was: "To assure that proper actions are taken to protect health and safety...." Yet no guidance was provided as to what
the NRC staff and the Director of IE should do or
how they should provide such assurance. The
directives to take appropriate action, 57 coupled withthe potential sweep of this objective, are broad
enough to encompass a wide-ranging intervention in
the licensee's actions by the NRC in response to an
accident, to direct such actions, and to supersede
the licensee's actions, if necessary, so that it would
be the NRC itself which assures "that proper actions
are taken to protect health and safety...." This,
however, was not the tone set elsewhere in the
NRC emergency planning documents, nor was it theunderstanding reflected by senior NRC officials.
The initial response action called for by this incident response plan was the dispatch of inspectors
to the scene. 58 These inspectors were to assess1082

"the threat and magnitude of the incident by direct
observation, and by discussion with the licensee
and local authorities...," and were to provide information to the Region and to Headquarters. 59 Rather than actively intervening to "assure that proper
actions are taken to protect health and safety
the onsite inspectors were admonished in the Region I Emergency Plan to limit their involvement to"objective observation, evaluation and investigation
and avoid being directly involved in directing and ordering actions by the licensee or other agencies...." This posture of limited involvement was tobe maintained "unless the61licensee's organization
significantly breaks down."
A provision in the IE Manual Chapter, and in the
Regional Plan, strikes a similar note. Although calli ng for NRC evaluation of the licensee's actions "toassure safe conditions," it states that if options toprovide further assurance of protection are identified by the NRC, the NRC was to "notify the authority or 62
agency responsible for taking appropriate action."
This suggests a role for NRC of "notifying"(or at most recommending) that someone else,
presumably including the licensee, may have an
available option that can further assure safety. Nowhere did the initial plan or the IE Manual mention
the stronger role of instructing
or directing the licen63
see to take any action.
Similarly, at least three regional directors, onthree very different occasions, have expressed very
like thoughts indicating that the NRC's function was
not to direct or manage response actions. 64 Theseviews are consistent with others expressed on occasion by the NRC. For example, in a memo to E.
Volgenau, Director of IE, dated May 26, 1976, B.
Rusche, Director of NRR, stated: "We must avoid
the idea that we can substitute for the licensee but
we must be capable of confirming that he has done
his job and that others (States, local governments,etc.) have done them. We must be in a position to
detect obvious deficiencies and suggest corrective65
If the focus is on those instances when
actions."
the licensee does respond correctly to the accident,
then these views of the NRC's functions vis-a-vis
the licensee are compatible with the ringing statement of good intentions in the initial plan: It is the
NRC's objective to assure "that proper actions aretaken to protect health." In these cases, it is sufficient for the NRC to confirm "that he has done his
j ob ...." However, there were no plans, and little
consideration of the planning necessary, to deal
with situations when the licensee is not correctly
responding to the incident. There was only thevague objective of assuring "that proper actions aretaken to protect health."108 3

b. Reassessment After Browns Ferry
After the Browns Ferry fire, there were a numberof actions taken relating to emergency response.
Three in particular have bearing on the NRC's
response to emergencies: the Browns Ferry Special
Review Group report, an internal study of NRC
emergency response culminating in a revision to the
NRC Manual Chapter 0502, and a study by the
MITRE Corporation to analyze NRC incident communications needs. Each of these studies was affected also by the availability of the information
developed by the Reactor Safety Study (WASH1400).
The Browns Ferry Fire Special Review Group
ReportAfter the Browns Ferry fire, a special internal
NRC review group was appointed to review the ac66
The reportcident and to make recommendations.
discussed the event in some detail, focusing on fire
prevention, and provided a number of recommendations. The report also touched on the problems ofcommunications and the difficulties such problems
could have caused if offsite action had been required67 and discussed the need for improved
emergency
response communications for the68
NRC.
With respect to the role of the NRC in emergency
response, the report admonished:
The NRC is responsible for assuring the health andsafety of the public and the safe operation ofBrowns Ferry and all other reactors. NRC provides
this assurance of public safety through the establishment of safety standards, evaluation of the safety of plants, and inspection and enforcement programs. The licensee, TVA, has the responsibility
for the safe design, construction, and operation of
its plant within the framework of the NRC regulatory
program. If the NRC were to become too closely
i nvolved in the licensee's operations, this might
have an adverse effect on the licensee's view of his
safety responsibilities. In other words, it is thelicensee's responsibility to operate the reactor
safely, and it is NRC's responsibility to assure that
he does so. (p. 7.)

Again, the report did not touch on the function of
the NRC in "assuring" that the licensee does his job
i n cases when it is unclear whether the licensee 69
isresponding correctly or incorrectly to an accident.
Grimes-Bryan Study

Although the Special Review Group warned
against becoming too closely involved, anotheri nternal study by B. K. Grimes of NRR and S. E.

Bryan of IE 70 addressed explicitly an "independent"role for the NRC in response to an accident.

Although a final judgment has not been made on
the precise role that the NRC should seek to play inthe event of a serious incident, the following overall
goal has been assumed for the purpose of this discussion paper as reflecting current staff opinion
and providing a broad framework for discussion ofvarious alternatives: The goal of NRC incident
response is to obtain and evaluate information inorder to have the capability to make independentjudgments with regard to the impact of licensee andother agency actions on the public health and safety and the common defense and security and tohave the capability to assist the licensee and otheragencies where possible and direct the licensee if
required. 71
A design basis accident which followed its expected course would involve only information gathering and evaluation by the NRC to confirm that
adequate actions were being taken by the licensee
and other responsible agencies. It should also be
noted that the need for active NRC involvement in
an incident is predicated on the failure of preplanned utility and State actions either because an
event different than planned for has occurred or
because of a breakdown in the execution of the
preplanned actions .... 72

On the other hand, the report acknowledged that,for many accident sequences, the time available forresponse by the NRC, made it impossible for the
NRC to take action to alter the course of events.
Further, the report pointed out the importance of theoperating staff's intimate knowledge of the facility. 73
The NRC's role as reflected in this report wasmore active than that suggested by existing NRC
plans and underlying material discussed above. The
report suggested a much more active evaluation of
the licensee's actions to determine adequacy andeven suggested active intervention, such as giving
advice or providing technical assistance. It went so
far as to explicitly recognize that there may be circumstances that warrant formal intervention by order, or "in the extreme, could, theoretically involve
onsite direction of actions." Yet, in terms of departure in intent, the report was not considered significant. 74 Testimony indicates that the draft report
expressed the generally held consensus of senior
managementon the NRC's role in emergency
75
response.
The remainder of the report made a number ofobservations and recommendations and included an
extensive list of potential accident scenarios and76
Recommendation
ti me estimates for such events.
was made that a senior management team be available to advise the IRACT on incident response
direction. This Management Advisory Team (MAT)
was to be similar in composition to the EMT eventually created, except that it did not include the EDO.

However, there was an important functional
distinction-the MAT was to be advisory to the
I RACT; the TRACT was to be the group responsible
for carrying out the emergency response under the
Director of IE, who was to serve77
both as head of the
MAT and as head of the IRACT.
The report recommended that the Directors of
the Operating Reactors Division, the Safeguards
Division, and the Fuel Cycle and Materials Safety
Division be added to the IRACT for incidents in theirarea of licensing responsibility. 78
The report mentioned but did not discuss at any
l ength the need for communications systems improvements, such as a system that "does not relyon the telephone network." 79 I t included a list ofparameters needed for incident assessment 80 andi ndicated, "One possibility for transmittal of the information to the IMC would be through a direct
hookup from an IMC computer to all plant computers. The feasibility of this type of hookup should be
evaluated. However, an immediate problem ofequipment compatibility arises and this method ofdata collection may not be feasible for plant information ...."81
This draft report was never finalized, but theoverall objectives of NRC incident response as set
forth on pages 3 through 5 are used essentially verbatim in revised Manual Chapter 0502.
The MITRE Contract

Toward the end of 1975, staff discussions concerning communications improvements for NRC
Headquarters in the event of emergencies, including
safeguards emergencies, were begun. By June
1976, work statements and preliminary estimates
were completed; MITRE Corporation was selected
as "sole source" for a contract to assist the NRC "indesigning command and communications procedures for the IE Incident Management Center." 82
The MITRE Corporation report 83 discussed elecommunications
arrangements forments ofresponding to nuclear incidents, basing those arrangements on characteristics derived from a set of
hypothesized incidents together with a premise"responsibility" on the part of the NRC. The reportoutlined three concepts:

1. A monitoring concept in which the "NBC's involvement would be limited to monitoring the activities of the various response units and coordinating Federal information exchange." It notes
that, "Although advice could be provided, delays
should be expected.... " 84
2. An advisory concept in which the source of data
and the source of requests for advice would be
the licensee's management. 85
1084

3. An advisory concept in which data are independently available to the NRC via telemetered sensor information. In this case, the NRC could advise the licensee concerning matters not yet considered by the licensee. 86 The report notes that
this capability "provides NRC the informationbase required to intervene in the licensee
response if it should ever be necessary."

The NRC selected the second of these concepts(advisory with dependent data) for planning, but indicated that such plans should not preclude upgradi ng the system to an independent data source concept. 87
The report was principally devoted to discussionof communications arrangements, and although its
88
discussion of NRC responsibility is overly abrupt,
the report makes this salient point:
There appears to be little doubt that the public willhold the NRC ultimately accountable for any hazards, regardless of any responsibilities formallydelegated to the licensee .... 89

With this premise of NRC obligation, and with incident characteristics based upon a set of hypothesized incidents, the report made a number ofcommunications recommendations:

1. I n order to enable onsite plant staffs to concentrate on coping with the situation facing them, thereport recommended that licensees set up an
offsite operations center (LOC) for offsite
management. The LOC would serve as the single point of communications for the licensees'
onsite staff. The LOC would also serve as the
single point of contact between the licensee's
management and the NRC, which would act as
the point of contact for Federal reponse; theState police, acting as the point of contact for local authorities; and one or two other points ofcontact with State authorities. The report recommended that this center be staffed at all hours,
and emphasized the importance of this central
point of control and contact away from the midstof the crisis response. 90
2. The report recommended an automatic orsemiautomatic early alarm to promptly notify boththe NRC and licensee management. It also
recommended 24-hour operation of the NRC
response center. 91
3. The report pointed out that a communications
system should generally reinforce the normal
functional relationships, including chains of command, among its users. Otherwise, the system
may inadvertently generate competition between
authorities or, alternately, it may keep 92
informationfrom the authority who really needs it.
108 5

I n addition to the various recommendations, thereport linked the communications system (the availability of information) to the ability to respond in aparticular fashion. This point was made explicitly in
discussing the concept finally selected by the NRC
for further development (option 2, above), the NRC
advisory, data-dependent role. The report notes:" The most obvious limitation is that the NRC must
depend on the licensee for details of the incident. If
the LOC doesn't anticipate a problem the NRC-OC
i s unlikely to have enough information to sense it, either. " 93A principal shortcoming of the report was theshort shrift given to the communication and control
relationships between the NRC Headquarters andthe Regional Office and the role of the resident inspector in those relationships. This was particularly
true in light of the point noted in the draft that acommunications system should reinforce normal
functional relationships to avoid the inadvertent generation of competition between authorities. Yet thereport showed communication from a distant NRC
Headquarters filtered through the licensee's
management to the site, and another chain from
Headquarters through Regional IE to the onsite inspector (and perhaps a three-way tie-in among
Headquarters, Regional Office, and onsite inspectors). It is unclear how this system was expected toreinforce the normal lines of authority in regard to
the onsite inspector and the Regional Office.
Another shortcoming, perhaps inherent in the nature of the contract to study the NRC's communications needs, was the failure to identify the communications needs of the licensee's operations center,needs that are basic to its ability to fulfill the vitalrole ascribed to it in the overall arrangement that thereport envisions. The need for such centers to havei ndependent sources of data (independent readout)
and the necessary staff to fulfill its role as "center"
for emergency response information are only
touched upon. Yet, this center was the linchpin of
the planning arrangements recommended.
Follow-up of the report focused mainly on the
NRC's end of the communication systems; e.g., purchase of a telephone taping system for IRC, layoutof IRC, arrangements for "satchel" radios and NEST
assistance for fieldwork (transportation accidents,
scripting, and review of IRC information gathering).
Revision of Manual Chapter 0502
The activities mentioned above led to the need torevise Manual Chapter 0502. The 1977 early drafts
were fairly simple modifications of existing 0502,
but reflected a new organization, with an Executive

Management Team (EMT), including the EDO, functioning in the overall decisionmaking role. This wasdifferent from the advisory role recommended in the
Grimes-Bryan study. An IRACT with additional
members, as suggested in that study, was also proposed.
The response role of the NRC reflected in the
Grimes-Bryan study was not reflected in the early
proposed revisions to 0502. However, a draft dated August 8, 1977, extensively revised the prior format of 0502 to reflect not only the changed organization for emergency response, but also to reflect
the objectives of evaluation, assistance, and direction articulated in the Grimes-Bryan study.
After a number of additional drafts and comments
by the various offices and divisions, principally relati ng to organizational structure and details, the revised Manual Chapter 0502 was adopted on February 6, 1978. There is no indication in these various
comments and revisions of any particular emphasison the significance of formally expressing as the objectives of the NRC, in connection with response toi ncidents at licensed facilities, that the NRC would:• evaluate information

gathered to determine
whether the actions taken up to that point by thelicensee and others will assure that effects on
public health and safety are minimized.
• determine what assistance to the licensee andothers is useful and provide assistance in theform of opinions, advice, and technical expertise.
• determine whether the situation warrants formalintervention by order or by onsite direction of action.
3. PLANS IN EFFECT MARCH 28, 1979
a. Headquarters Plan
GeneralI n order to accomplish the objectives discussed
94
above, the NRC Incident Response Plan createdan incident response organization. This organization consists of an Executive Management Team
(EMT), which "transforms" general policy provided
by the Commission into "specific guidance for the
response organization and makes major decisions
affecting NRC's response actions," and an Incident
Response Action Coordination Team, IRACT, which"executes EMT decisions by directing activities of
the IRACT support staff," and which "provides information to EMT." The IRACT was also to identify
significant problem areas, develop alternate solutions,and present alternatives to the EMT for deci95
sion.

The EMT is constituted by the Executive Director
for Operations, who served as Director, the Directorof IE, the Director of NRR, and the Director of
NMSS. For reactor accidents, the four Division
Directors of IE and the Director of Operating Reactors of NRR constituted the IRACT, with the IE
Director of Reactor Operations Inspection as Director of IRACT. 96
There was also to be an "IRACT Support
97
While admonishing that detailed actions to
Staff."
be taken by the IRACT Support Staff are incidentspecific, the Manual nevertheless specified certain
functions assigned to NRR, others to IE, still others
to State Programs, and others to Public Affairs. The
NRR staff was assigned the functions of evaluating
i nformation on the likely future course of the incident, evaluating the corrective actions proposed
and taken, evaluating the feasibility of assistance tothe licensee, and evaluating the need for formal intervention by the NRC. The IE staff was assigned
the functions of assuring that personnel aredispatched to the site to "monitor licensee activities," gathering information concerning the incident"to assist in NRC's independent evaluation of effectsof the incident," and performing "inspection and investigatory functions in the field required to assure
the health and safety of the public and to provide in98
formation requested by EMT or IRACT."
Procedures to implement the broad program out99
Theselines of the Manual were developed by IE.
procedures, set forth in the NRC Headquarters Plan,covered:• call lists and communications with other agen•
•
•
•
•
•
•
•
•

cies, whether State, local, DOE, DCPA, EPA (andWhite House, DD, FDA, and others as needed);handling initial notifications through various potential channels, during and after duty hours, including a form covering certain basic information;
activating the Incident Response Center, including
i dentification of certain initial steps to be taken byvarious staff members;
emergency communications assistance;
emergency transportation arrangements;
general organization of the EMT;
general functions of the IRACT;EMT-IRACT interaction;
general description of duties of certain staff
members;
a directive to contact specified members of
OELD in the event that EMT determines an order
may be needed.

Apart from its emphasis on "encouraging licensees to take the lead in information activities related100
the 1978 Manual Chapter, unlike theto incidents,"
1976 version, provided little discussion of public in1 086

formation procedures. Rather, the Manual Chapter
called for an implementing procedure
to be
101
developed covering public information.
However,the entire implementing procedure consisted of thestatement:

Any request for information from members of the
public will be referred to the Office of Public Affairs
representative in the IRC. Obtain requestor's nameand the phone number where he may be reached.
The Office of Public Affairs will be
102 informed; a return call will be made by PA staff.

The procedures in the plan of the IE Division of
Reactor Operations Inspection identified specificstaff functions such as "Technical Coordinator" and" Field Communicator," and made specific personnel
assignments for the various functions.
Organization Interrelationships

With the Commission-The NRC Incident Response
Plan contained no role for the Commission in emergency response. Other than references to assuring
notification of the Commission in the event of an
emergency, the Commissioners were seldom mentioned in the NRC Incident Response Plan. The
Commission was shown as the top box
on the In103
cident Response Organization Chart,
and theprovision for postaccident investigations indicatedthat the Commission may prescribe a different organization for carryingout investigative activities
104
The
discussion of the "Concept
after an accident.
105
of Operations"stated, "The Commission provides
general policy which determines the overall courseof action NRC takes in response to incidents ...."
Though the Commission could interject to "provide general policy" guidance in the midst of an accident, and indeed could modify the response planset forth in the Manual if necessary, it is obviousthat the plan was designed to be carried out without
direction from the Commissioners and without aspecific role assigned to them. The responsibilities
for carrying out the plan and for106
taking any required
action were vested in the EMT.
Between EMT and IRACT-The role of EMT in theplan was that of "major" decisionmaker, with IRACT
actually supervising the gathering of the information
upon which such "major decisions" were to be
based and actually supervising the myriad tasks tobe performed by the staff in carrying out such "maj or decisions."
The implementing procedures along with thephysical layout reinforced this confined role for
EMT-dedicated to "major decisions," apart fromthe hurly-burly of information gathering.
1 08 7

EMT was located in a room
adjacent to, but
107
separate from, the IRACT room.
Communications
between EMT and the IRACT Operations Room wasthrough an EMT-IRACT liaison officer who was toperiodically brief EMT on current status and to identify "principal questions" being pursued and actions
being taken by IRACT. If EMT had any questions,they were to be posed in writing to the liaison officer who was then to keep track of all questions
submitted. EMT members were admonished to "lim108
it their intrusion into the Operations Room."
I RACT was to provide "adequate" information to
EMT; however, it was directed to provide an evalua109
tion of information-not unevaluated raw data.
NRR and IE formally agreed on March 21, 1977,
that IE would manage the incident response "until
the Executive Management Team is available," andthat EMT, when available, "will assume full management of NRC incident response activities." 110 However, no further organizational plans or arrangements for the management of the incident by EMT
were established, despite the fact that the formal
agreement among Office Directors was at odds withthe then existing arrangements under Manual
Chapter
0502 of 1976 and IE Manual Chapter
111
1300.
When the Manual Chapter and the Headquarters plan were modified in 1978 to reflect EMT,
the role turned out to be as described above, that of"major" decisionmaker, rather than one of "fullmanagement."
Between IRACT and Staffing-The NRC plan did not
identify how the IRACT was to function; that is,whether it was to function as a body, or whether individual members were to supervise specific components of the support staff, or whether the IRACT
members were to be assigned supervisory roles asnecessary. Nor did the plan discuss how the support staff was to be supervised by the IRACT. In
this regard, it should be noted that, though four outof five members of the IRACT were to be from IE,
the bulk of the evaluation was assigned to NRR, with
IE assigned principally an information gathering role.
Similarly, the implementing procedures did not discuss how the five-member IRACT was to function inorder to discharge its supervisory role. The procedures simply lumped together the IRACT support
staff functions without dealing with how the functions assigned by the Manual to separate divisions
were to be organized and supervised by the IRACT.
Specific role assignments for reactor accidents
were provided in the plan only for the IE Division of
Reactor Operations Inspection. These role assignments, which provided for complete staffing of allroles by IE personnel, were intended to apply only
when the IE Division of Reactor Operations Inspec-

tion was the sole or principal responding organiza12
tion 1 They were not intended to govern the situation after NRR undertook participation in the
response to a serious incident. However, they appear to have been the only set of written, preplanned role assignments for reactor accidents.
There were, in short, no preplanned organizational arrangements or role assignments for carryingout the vital assessment functions along the divisional lines outlined in the Manual Chapter. The
NRC's plan for incident response simply did not deal
with organization of people not used to working witheach other, people from different divisions within theagency-divisions between which historically there
has been some sense of rivalry and friction.
b. Regional Plan
The Regional Plan, in contrast to the Headquarters Plan, was organizationally straightforward. It
provided both general policy guidance and areas offairly specific guidance and instructions. There
were, however, two important areas of ambiguity in
the Regional Plan when viewed in connection withthe overall NRC plan. One was the relationshipbetween the Region and Headquarters; the second
concerned the NRC's function in the event that (andcriteria for determining when), the NRC's response
should transcend "the investigative role." These are
discussed separately below.
The Regional Plan was initially developed in August 1977, and was very similar in general approach
to IE Manual Chapter 1300. However, as noted
above, this IE Manual Chapter was developed inconnection with the initial 1976 NRC incident
response plan. Although the Regional Plan had
been modified to reflect the newer organization of
the current Headquarters Plan, consideration offurther modifications to more closely reflect the
113 new
The
Headquarters Plan had begun only recently.
Regional Plan specifically provided for an incident
response organization under the overall authority
and supervision of the Regional Director or the
Deputy Director. The organization consisted of a
Regional Incident Response Action Coordination
Team (RIRACT), headed by the affected branch
115
14
chief, and an Onsite Inspection Team (OIT).
The RIRACT was responsible for the overall
118
It
coordination and control of Regional response.
was to select the team and its leaders to bedispatched to the site. 117 The RIRACT was also
responsible for assessing any incident characteri zed as, "collectively the responsibility of the Director, Deputy Director,
118 and responsible Branch andSection Chiefs...."An OIT was to be dispatched to all significant incidents to gather information concerning the incident and to observe and evaluate the licensee's
efforts to respond to the emergency. 119 The teamwas directed to provide radiological assistance tothe licensee
or to others until relieved by other120
agencies.
In circumstances of life or death, or in those
directly affecting the public health and safety, theplan indicated that radiological responsibilities supersede normal regulatory
functions until the situa121
tion is under control.
I n addition to overall policy guidance and generalorganizational instructions, the plan also contained
fairly specific guidance and instructions concerning
response actions by various regional participants. 122
These included specific notification procedures,
guidance on the specific data to be obtained after
notification of an incident, guidance for classifying
the severity of incidents, guidance on specific information to be obtained by RIRACT, guidance on
specific information to be obtained by OIT, plans fordrills, lists of equipment to be available, guidance as
to emergency radiation exposure, projected dose
guidance for protective actions off site, guidance
concerning public information statements, lists ofconsultants and other agency contacts, and lists ofli censees.
The Regional Plan guidance was far more specifi c than that in the Headquarters Plan concerning
public information procedures. The Regional Plan
gave as its objective making the facts known "sothat possible health hazards and precautions will be
understood, undue public alarm will be avoided andscare stories written in the absence of facts will be
at a minimum." It emphasized the need 123
to authenticate facts and to avoid speculation.
Thoughspecifically indicating that public announcements
normally were to be issued by the licensee, the Regional Plan went on to state that the licensee was
not 124
to be used as spokesperson for NRC activities.
c. The Relationship Between Headquarters
and the Region

Each plan imposes very similar responsibilities on
different groups, though little was said about theiri nterrelationship aside from essentially hortatory
guidance to "coordinate."
The Regional Plan contained a number of references to coordination with the Headquarters IRACT,and the organizational chart shows the Headquarters IRACT in a box above that of the Regional
Director. However, the language used throughout
1 088

the Regional Plan to discuss responsibilities suggested that it was the responsibility of the Regional
officials
125 to carry out the various response funcThe plan called for Regional officials andtions.
the onsite team, as the first line, to determine theparticulars of the incident, assess the magnitude of
the hazard to the public, and determine whether
adequate protective and corrective actions werebeing taken. These functions entail the exercise ofa significant degree of technical judgment.
The overall NRC plan, however, delegated thesesame judgment functions to other components of
the NRC staff; the Headquarters Plan called for NRR
to evaluate the likely future course of the accident
and the corrective actions being taken in responseto the incident. NRR was also responsible for
evaluating the need to provide assistance to the126
li censee or the need for formal NRC intervention.
On the other hand, the NRC Headquarters Plan
assigned to IE the functions of monitoring theli censee's activities, gathering information for the
NRC's independent evaluation (presumably theevaluations assigned to NRR), and providing information requested by EMT and IRACT. But this plan,too, contributed to the conflict by also specifyingthat IE "performs inspection and investigatory functions in the field required to assure health and safety of the public...." This function, during an ongoi ng event, is broad enough to encompass any andall the activities then underway to stabilize an unstable situation and to prevent or mitigate serious
potential releases.
These overlapping organizational functions may
be of little significance in a fairly well defined situation. However, in a situation with substantial uncertainty and with the potential for serious danger, thescene is set for conflicting perceptions between
people on site and those at Headquarters who may
be receiving information from sources other than thesite or from people with a wider range of background. These conflicting perceptions can lead toconflicting priorities regarding information to begathered or action to be taken. To cope with thispotential, the Regional Plan simply called for "coordination" with Headquarters; the Headquarters Plan
did not do that much.
d. Difference in Role Played by the NRC
Although it can be argued that the overall NRC
role reflected in the Regional Plan was essentiallythe same as that reflected in the Headquarters Plan,
the basic thrust of these two plans was very different, just as the basic thrust of the NRC's role re-flected in the NRC's initial plan was significantly different from that reflected in the current plan.
The role depicted in the Regional Plan is somewhat easier to describe, although it too has complex
characteristics. Essentially, the role described for127
NRC response to an incident was "investigatory,"
with the additional responsibility for providing radiological assistance until such time as NRC personnel
could be relieved. 128 I n circumstances of life ordeath, or when public health and safety are affected
directly, the radiological responsibilities were to supersede normal regulatory functions.
Even for the radiological assistance role, thefunction was essentially a backup one to be terminated when "other groups with this specificresponsibility (e.g., DOE-RAP)"
arrive, or "when the129
situation is in control."
While the Regional Plan called for the onsite teamto "assure that actions are being taken to protect
people...," to "determine the magnitude of the
problem and the hazards to the public," and to"determine what actions the licensee is taking to assure safe conditions... ,"130 the plan makes it clearthat Region I personnel at the scene were to becareful to limit their involvement to "objective observation, evaluation and investigation and avoid being
directly involved in directing or ordering actions by
the licensee or other agencies unless the licensee's
131
organization significantly breaks down."
The Region I plan did not mention this situation
again. Thus, it provided no criterion for judgment,
except as inherent in the rather drastic phrase, "significantly breaks down," which suggests a fairly
severe132 degree of inability to cope with the situation.
Except for the "radiological assistance" roleas needed, there is little if any mention of the NRC's
providing recommendations or advice to the licensee on how to cope with a situation he may be faci ng.
The Headquarters Plan suggested a much more
active role. The determination of whether to intercede by providing advice or formal direction ofoperations entails a very active involvement inevaluating the situation and the actions being takenby the licensee. Moreover, the placement of this
responsibility with offsite Headquarters NRR staff,
rather than with the onsite inspector, tended tomake this judgment independent of (or isolated
from, depending on one's point of view) direct influence from the licensee's personnel. Yet, in the absence of an independent source of information, thei ndependence of judgment may be illusory, and isolation from the actual situation on site may be domi nant.
Although the Headquarters Plan expressed theconcept that it may be necessary for the NRC to in108 9

• Providing technical assistance to the licensee, if

tercede in the licensee's response to an emergency,
the absence of any preplanned criterion for such intervention left the situation as ambiguous as the Regional Plan's use of the phrase, "unless thelicensee's organization significantly breaks down."
However, in the case of the Regional Plan, the judgment of when such an event takes place was in thehands of the onsite inspection team. It is unclear
who decides what to do thereafter. In the case of
the Headquarters Plan, the judgment of when to intercede and what to do was in the hands of thesenior-most staff of the agency, but based on information filtered through a Headquarters staff whichitself, at best, had secondhand information ofperhaps undefined quality.

needed, such as technical suggestions andevaluations of alternatives proposed by the licensee, to alleviate some of the burden on the licensee in his efforts to cope with the problem;• Providing the State with monitoring and radiationassessment assistance, contributing to TRAP support, and assisting the State to obtain any needed resources available from the Federal Government;• Providing the important supportive role of communicating information to the public and to
government officials.

After the Browns Ferry fire, and the subsequent
publication of WASH-1400, some of these concepts
began to change. The NRC explicitly expressed arole for itself as potential overseer of the licensee's
response: evaluating the actions the licensee istaking, providing technical advice to the licensee
and thus influencing actions, and possibly (in what
are characterized as highly unlikely circumstances)
deciding that the licensee is not doing what needs
to be done and, so, stepping in to direct actions.

4. CONCLUSIONS
a. Role Perceived by the NRC
Prior to the TMI accident, the NRC's concept of itsrole as an agency in the event of a serious nuclear
accident was an ambiguous "third-party" role-oneof backup support of the primary roles to be playedby the licensee and the State-with some vague
sense of the need to do something if the licensee
failed in its primary role.
This backup role is not one imposed by the
Atomic Energy Act. The Act does not define a
specific role for the NRC in an emergency. Because
the NRC is not provided with police powers that
may be needed to effectuate offsite protective actions, State and local authorities must play a vitalrole. However, this does not restrict the NRC fromtaking an active role in determining the need for,and taking the lead in, marshalling crisis response
actions.
The backup role appears to be based on, or atleast coincides with, a series of concepts about thecharacter of accidents. The result was a framework
i n which reactor accidents were envisioned to bewell understood, rapidly diagnosed events calling forprompt plant actions by the licensee. The licensee
was thought to have the most complete, mostcurrent information, as well as an intimate
knowledge of all aspects of the facility. Such accidents also called for prompt decisions on offsite
protective actions and, thus, for close communication between the licensee and State and local authorities. However, such offsite actions, if needed,would be required only in limited areas very near thesite. Against this framework, the principal role for
the NRC, in response to the crisis stage of an accident, would logically seem to be one of support tothe licensee and the State:b. Overall NRC Organization Planning
While these objectives were expressed in the
NRC's plan for incident response, the agency's
preparations were not at a stage where such objectives could reasonably be fulfilled.
Although an NRC study of communications madea number of recommendations for a necessary
overall communications structure to accomplishthese functions, only a few recommendations relati ng to specific items had yet been implemented.
Thus, at the time of TMI, the NRC's communications
systems were highly dependent on information supplied by the licensee: there were no arrangements
for early notification of the NRC, and there were no
arrangements for direct communications between
li censee management and the NRC. Indeed, there
were no NRC-induced arrangements for earlymarshalling of the licensee's management andoffsite resources for prompt support of the onsite
operating staff.
Moreover, the NRC's internal organization had
not been coordinated to fulfill these goals. The
overall NRC incident response plan had beenchanged from an IE operation (with assistance fromother offices) to one in which there was a major role
for the NRR component, without any specific planning for how the efforts of this component were to
be directed and coordinated in the overall response.
Nor was there any clear assessment of how these
109 0

changes would affect interrelationships with the Region and the field team of regional inspectors
dispatched to the site. Confusion about the role ofthe field response personnel was inevitable. The
Regional Plan suggested that the field personnel
were responsible for assuring that things were being
done properly to protect public health and safety, a
responsibility that carries with it the exercise of professional technical judgment. The Headquarters
Plan, however, separated the information-gatheringfunction of the IE component from the assessment

1 09 1function of the NRR component, thus leading totreatment of field personnel as sources of nuggets
of information to be put together by Headquarters
evaluators.
Telephone communication in a crisis situation,
particularly in relaying complex concepts, is difficult
enough under the best of circumstances. When thepeople on opposite ends of the phone have different
understandings of their respective roles, the situation is destined to result in misunderstanding.

REFERENCES AND NOTES'Atomic Energy Act of 1954, as amended (The Atomic
Energy Act or "the Act") 42 U.S.C 2011 et seq., asamended by the Energy Reorganization Act of 1974, as
amended (The Energy Reorganization Act), 42 U.S.C.
5801 et seq.
2
Although such a serious accident is postulated as thepremise of the Price-Anderson financial protection provisions of the Act (Sec. 170), the Act does not deal explicitly with any other aspect of response to serious nuclear
accidents except as encompassed by the broad grants ofregulatory authority to the NRC over safety issues; e.g.,
to establish by rule "such standards... to govern the possession of [materials] as the Commission may deem
necessary ... to protect health or to minimize danger... "(161b).

3
A legal analysis was carried out by the Federal
Preparedness Agency (GSA), in April 1977, as part of its
study, "Federal Response Plan for Peacetime Nuclear
Emergencies (Interim Guidance)." This analysis, Annex II,
concludes very broadly that, "there appears to be no lackof legal authority to respond to Category I emergencies[defined as minor and localized] and, to the contrary
there is a legal obligation imposed upon the NRC andERDA to take prompt and effective corrective measures..." (p. 4). It also concludes, for Category II
accidents (defined as having the potential for widespreadcontamination and encompassing a major accident at a
power reactor) that, "The authority of the President andthe Federal agencies involved to respond to such an
emergency appears clear with no lack of legal authority
to respond to the needs of this contingency..." (p. 9).
This analysis weaves its discussion of agency andpresidential powers over a range of circumstances covering both accidents and deliberate acts. Broad conclusions, supported only in part by the references, arereached. With respect to the NRC, the statutory citations
are to the general regulatory provisions of the Atomic
Energy Act, Secs. 11, 41, 53, 57, 62, 81, 92, 101, 170, 183,
274, and to the criminal, violations provisions, Sees. 221,
222, 223.
I n commenting on the draft of this report, the Office of
the Executive Legal Director stated that, "none of thisauthority [the authority cited by the author of the report],
standing alone, has any direct bearing on the subject
under consideration, i.e., the responsibility and the extent
of NRC's authority to respond to a nuclear emergency
during the time the emergency exists. On that subject, it
would be far more appropriate, for example, to discuss
Section 108, which is the only provision giving NRC clear
authority to act directly, and then only pursuant to a
Congressional declaration of war or national emergency...." It recommended that, "the references to theprovisions of the Atomic Energy Act and Energy Reorganization Act as they relate to NRC be deleted in their
entirety, and that there be substituted a legal analysis
which will be relevant to the matters under consideration."
This comment was forwarded to the Federal
Preparedness Agency by Harold Collins of the NRC on
January 11, 1977; however, the final report does notappear to have changed in this respect.
4

Act.

ERDA-DOE function under the Energy Reorganization

The Commission has often appeared to describe thisas a limitation on its authority in the field of emergency
planning, in that it has no authority to direct the States toprovide emergency planning. This disregards the rather
plenary scope of its authority over licensees to assure
adequate safety. In the event of inadequate emergency
planning or inadequate emergency response ability on thepart of State or local authorities, the Commission may
simply assess the safety of the facility design for its
i ntended use at a location at which there is inadequate
State and local emergency response capability. The
Commission may require extensive additional safety precautions (or a lower acceptable probabilistic risk goal), if
these are capable of compensating for inadequate emergency planning. If not, it may deny or suspend authority
to build or to operate the facility.
6
These concepts are seen in a wide range of NRC
material and in material produced by other Federal agencies that have worked with the NRC on various aspectsof guidance concerning emergency planning.
7"Planning Basis for the Development of State andLocal Government Radiological Emergency Response
Plans in Support of Light Water Nuclear Power Plants,"
USNRC and USEPA Task Force on Emergency Planning,
December 1978, NUREG-0396, EPA 520/1-78 016.
8
For example, "based on past experience ... a distance of 3 miles to the outer boundary of the low population zone is usually adequate" (Reg. Guide 4.7, Sec. C.3).
Even if the 25 rem thyroid dose PAG is considered (adose that is significantly lower than the 300 rem thyroid
dose value of Part 100), the techniques used in NUREG0396 indicate that, following a DBA-LOCA, such doses
will be within a radius of two to five miles (see pp. 1-27 to1-30).
A greater distance is required for actions that may benecessary to avoid dose through the milk pathway. Thisdistance may be required even for an incident limited to a
design basis loss of coolant accident (NUREG-0396, p.
1-35). However, a greater period of time is available
before human exposure occurs (NUREG-0396, p. 14).
9NUREG-0396 follows the quoted sentence with thestatement: "The Task Force, after considering the published guidance and available documentation .... concluded that Class 9 accidents have been given someconsideration in emergency planning." The sentencerefers to four documents:
1. "Radiological Incident Emergency Response Planning
Fixed Facilities and Transportation:
Interagency
Responsibilities," Federal Preparedness Agency, General Services Administration, Federal Register Notice,Vol. 40, No. 248, December 24, 1975.
2. "Reactor Safety Study: An Assessment of Accident
Risks in U.S. Commercial Nuclear Power Plants"(NUREG-75/014),
October
1975,
WASH-1400,
USNRC.
3. "Disaster Operations, A Handbook for Local Governments" (CPG 1-6), July 1972, and "Change No. 1," June
1974, Defense Civil Preparedness Agency.
4. "Federal Response Plan for Peacetime Nuclear Emergencies (Interim Guidance)" April 1977, Federal
Preparedness Agency, General Services Administration.
5

109 2

The third reference recommends that there be plansfor dealing with incidents "affecting a substantial area outside the facility site" (p. 68b). The fourth reference
recommends plans for dealing with incidents ranging up
to"situations
inwhich,
despiteall
preventive ... efforts ... widespread contamination, shallhave occurred..." (p. 17).
The discussion in the fourth reference concerning
serious events (Categories II, 111, and IV), though mentioning reactor accidents as a source of such events, heavily
emphasizes sabotage and threats of deliberate acts, aswell as weapons events (see pp. 15-16,18, and Annex I,
pp. 6-7, 29-31, 43-47).
Although the second reference, in part, considers theeffect of protective actions such as evacuation in mitigating the consequences of severe core melt accidents, itcannot be characterized as recommending the need forextensive evacuation plans for each operating reactor.
0'See Reg. Guide 1.101, Annex A, 4.1.5: "An acceptable
planning basis [for General Emergency plans] is the mostserious design basis accident analyzed for siting purposes."
See also "Guide and Checklist for Development and
Evaluation of State and Local Government Radiological
Emergency Response Plans in Support of Fixed Nuclear
Facilities," USNRC, Office of International and State Programs, Revision 12/1/74, NUREG 75/111: "The AEC considers that it is reasonable, for purposes of emergency
planning relative to nuclear facilities, to prepare for the
potential consequences of accidents of severity up to andi ncluding the most serious design basis accident analyzed
for siting purposes.... The AEC recognizes that
accidents with more severe potential consequences thandesign basis accidents can be hypothesized. However,the probability of such accidents is exceedingly low.
Emergency plans properly designed to cope with designbasis accidents would also provide significant protection
against more severe accidents, since such plans provide
for all of the major elements and functions of emergency
preparedness..." (p. 4).
See also Standard Review Plan, Sec. 13.3: "The planning should reflect, in particular, commitments to the following: (a) For an accident of the type postulated pursuant to 10 CFR Part 100, the initial assessment measures
should assure a capability for prompt notification to
offsite authorities, i.e., within approximately fifteen
minutes of detection of the initiating event."
See also the following AEC and NRC licensing cases inwhich emergency planning adequacy is assessed interms of design basis accidents or the requirements of 10
C.F.R. Part 100: Midland 6AEC331, Catawba 7AEC861,
Limerick 7AEC1098, San Onofre 8AEC957, Seabrook
1NRC613, 3NRC857, and 5NRC733, Marble Hill 6NRC1101,
Jamesport 7NRC826, Three Mile Island-2 8NRC9.
In Jamesport, specifically, the Board assessed emergency plans in terms of the DBA, but went on to hear evidence to assure itself that, "in the remote possibility of an
accident more severe than a design basis accident, no
insurmountable difficulties to evacuation were posed by
the Jamesport location...." However, the Board "did not
require ... that Applicant devise... definitive plans ... sincesuch mandate rests with [the County] and the State..."(7NRC854). In short, while looking at the "remote possibility" of an accident greater than the DBA, the Board did
not consider as part of its finding of "reasonableassurance" that such plans be required as conditions of
the license. Moreover, it found as fact that the county
could take adequate steps when the county argued thatsuch steps were not feasible (7NRC856).
In Seabrook 3NRC857, the Licensing Board "recognizes that the potential consequences of such [Class 9]
accidents form, at least in substantial part, the basis forState and local radiological emergency plans." However,the Board goes on to conclude that, under the NRC
requirements, the licensee need not consider evacuationor otherprotective measures outside the LPZ(3NRC926). Again the Licensing Board does not consider as part of its findings of "reasonable assurance"that plans to deal with events greater than design basis
accidents should be assessed or required as part of theconditions of the license.
The Manual of Protective Action Guides and Protective
Actions for Nuclear Incidents, USEPA Office of Radiation
Programs, September 1975 (Draft?), indicates on page 1.9
that, in the absence of available information during thecourse of an accident, "default values should be available
from planning efforts. These values could be based on
scenarios from WASH-1400, design basis accidents
evaluated in the NRC safety evaluation reports for individual facilities, or other scenarios ...." The enormous
potential difference in response to uncertain events thatwould be associated with assumptions based on WASH1400, as distinguished from those based on the DBA
assumptions, is not mentioned. In fact, after again referring to WASH-1400 as indicating that, "there is anextremely wide spectrum of different kinds of possible
releases to the atmosphere depending on the severity
and the exact sequence of the failure modes..." (p. 5.2),
the Manual goes on to state that it is usually conservative
to assume a fission product release based on NRC guidance for DBA assessment and states that, "[In] theabsence of more accurate information regarding release
composition, it would be conservative to assume that thiscomposition is released ... at the design leak rate" (p.
5.3).
"See Reg. Guide 1.101 C.: "Planning and implementation of measures to cope with plant-related emergencies
outside the site boundary with particular emphasis on the
low population zone should be a coordinated effort...."
See also Reg. Guide 1.101, Annex A, Sec. 4.1.5:"Although the likelihood of occurrence of such an event isextremely low, emergency plans should include a General
Emergency class which provides for early warning of the
public and prompt initiation of protective actions within
the low population zone...."
See also 1970 Guide to the Preparation of Emergency
Plans: "The licensee should give particular attention toprotective measures that may be necessary for individuals within the low population zone..." (Sec. IV).
See also cases cited in 10, above, and Point Beach
4AEC689, and Shearon Harris 7NRC92. See especially
Seabrook 5NRC733 in which the NRC staff argued thatemergency evacuation planning requirements should, inthat case, extend beyond the LPZ. The Appeal Board
held that, "we adhere to our uniform prior holdings that,
under the Commission's regulations in their present form,
consideration is not to be given in a licensing proceeding
to the feasibility of devising an emergency plan for theprotection (in the event of an accident) of persons locatedoutside the low population zone..." (p. 747).

109 3

12
The values selected in the EPA Manual of Protective
Action Guides, note 10, above, are: For airborne exposure: 1 to 5 rem whole body and 5 to 25 rem thyroid (pp.
2.3 and 2.5). The Part 100 values are, for different purposes: 25 rem whole body and 300 rem thyroid.
13
See Reg.Guide 1.101, Annex A, Sec. 6.4.3.2: "Protective actions planned for the low population zone with provisions for extending such actions to areas farther fromthe site boundary, if necessary, should be described...."
See also Reg. Guide 1.101, Annex A, Sec. 4.1.5: "Provision should also be made for modification or expansion ofprotective actions, based on conditions prevailing at thetime of an accident, to include areas in which projected
doses to individuals would be likely to exceed the upperli mits of protective action guides."See also Standard Review Plan, Section 13.3: "If supported by an assessment of the specific plant and site
situation, this region [the region for which emergency
planning should be provided] should be extended beyond
the LPZ. The principal criteria to be employed in thisregard include ... and (b) a comparison of projected
doses from postulated releases with Federal guidance on
those protective action criteria which might mandate thei nitiation of an evacuation, i.e., upper limit values whereranges are given."
The staff argument in Seabrook 5NRC733 wasdirected toward protection against the lower exposurel evels (5NRC748, but see 5NRC752).
The Commission ruling in response to the Appeal
Board Seabrook decision similarly appears to be directedprincipally toward planning beyond the LPZ, "taking into
account the emergency protective action criteria
developed by appropriate Federal authorities and by
appropriate State and local governmental authorities incooperation with the Commission" (43FR37473, August23, 1978). However, the statement of considerations also
contains the concept of optionally providing protection
above that called for by 10 C.F.R. Part 100: "Particularattention is to be given to the foregoing as they affect theeffectiveness of taking protective actions within the LPZ
established pursuant to the Commission's siting criteria of
10 C.F.R. Part 100. This should not, however, preclude
the consideration of utilizing emergency plans to provide
additional protective benefit to persons beyond a LPZ asa matter of reasonable and prudent risk management, toassure protection beyond that afforded by safety design
features and the siting of facilities in accordance with 10
C.F.R.
Part 100."14
See, for example, comments on the draft of
NUREG-0396 by M. Reilly, Chief, Division of Environmental Protection, Pennsylvania Bureau of Radiological
Health, dated August 11, 1978, to D. Snellings, Jr., Director,
Division of Radiological Health, State of Arkansas, copy
provided to NRC-OSP. Reilly indicates:"5. The added feature of substantial particulates andthe concept of doses to the order of 200 Rad at 10 miles
cannot be offered cavalierly. Those who believe thatplanning for this consequence would not be burdensome
have no idea what is involved in treating one let alone
hundreds of casualties of 200 Rad (and more) exposures.
It is a lot beyond putting them up in armories and passing
around cookies and milk."
15
i'd. Reilly (see 14, above) goes on in his comments tosay:"6. Regarding the matter of planning for accidents
yielding 200 Rad at 10 miles it is not difficult to estimatethat doses at one mile would approximate 6K Rad and1094

23K Rad at a quarter mile. If, indeed, this scenario isbelieved to be of sufficient probability to require planning,
it becomes the duty of the CRCPD [Conference of Radiation Control Program Directors] to reject this technology."
See also comments dated March 1979 on NUREG0396 by the Citizens Committee for a Better Environment: "A second basis given for the 10 mile EPZ comesfrom analysis using RSS methodology. The model is nowhere described; the results are presented with orthodox
RSS inscrutability. It appears that, for a core melt
accident (given the numbers in the RSS and some illdefined meteorology) doses of the order of the PAG of 5
rem whole body radiation are moderately probable up to
100 miles away; massive doses (greater than 200 rem)are possible around the reactor, but their probability
drops off sharply beyond 10 miles or so. At this point alli deas of responding to to PAG levels are dropped, since it
is clearly impossible to prepare for emergencies up to 100
miles away from the reactor. However, since short-terml ethal doses are only found within about 10 miles, this istaken as confirmation of the 10-mile EPZ concept" (p. 4).
18
44 FR 61123, October 23,1979.

17
Compare this to testimony by Chairman Hendrie atthe Hearing on Radiation Protection-Emergency Planning
Before Subcommittee on Energy, Nuclear Proliferation
and Federal Services, Committee on Governmental
Affairs, U.S. Senate, May 9, 1979: "To take an extreme
case, it would not be useful to provide for an evacuationthat was 99.9999 likely never to happen" (p. 117). This is
more like 10' 8 per reactor lifetime or 10 -7 per reactor
year.
18

NUREG-0396, p. 1-45.

'aNUREG-0396 cites the Reactor Safety Study,
WASH-1400, as indicating that major releases may begin
i n the range of 'i4 hour to as much as 30 hours after thei nitiating event (p. 18). See also Grimes-Bryan study(note 70, below), Appendix A.

20
See Grimes-Bryan study (note 70, below), Appendix
A. Of 17 scenario outlines for large break LOCAs, five forsmall break LOCAs, and four for reactor transients, 12
mention decision points for evacuation within 1'/4 hours of
the onset of the event. Five more that do not mention
decision points have very large releases within 200
minutes after the event begins. Four do not have severe
offsite consequences.
See also NUREG-0396: "The time available for actioni s strongly related to the time consumed in notificationthat conditions exist that could cause a major release orthat a major release is occurring. Development andperiodic testing of procedures for rapid notification areencouraged" (p. 19).
"Throughout both of the intervals from 0 to 10 miles,
the importance of a rapid and efficient implementation ofeither evacuation or sheltering is evident (small delay
times for evacuation, small ground exposure times for
sheltering)" (pp. 1-49 to 1-50).
"Note that evacuation (i.e., removal of population fromhazardous area) with delay times of 1 hour or less will
reduce the projected number of early public healtheffects to roughly 0 in any radial interval, and will always
be the most effective response measure for a severe
accident, if it can be achieved."
See also NUREG-75/111: "In some situations, there
could be a geed for protective measures within short timeintervals a half hour or perhaps even less after determination that a hazard exists. For this reason, emergency

planners should recognize the importance of prompt
accident assessment at or near the source" (p. 3).
See also 10, above: "Within the general framework ofproviding maximum health protection for an endangered
public, the public official charged with response to ahazardous situation may be faced with a number of decisions which must be made in a short time.... The effortsof planning activities can usually be based on the needfor immediate response" (p. 1.2).
Assumptions... Significant
releasesof"Releaseradioactivity may occur within 1 1/2 to 2'/2 hours of the initiating cause of the incident; therefore, if protective
actions are to be effective, they must be taken promptly"(p. 5.2).
The most vivid displays of the concentration on very
short, very well defined and understood scenarios are thedescriptions used to evaluate the adequacy of emergency
planning in the Jamesport case and in the TMI-2 case.
In Jamesport 7NRC826 the sequence of events is
described as: "Based on a step-by-step analysis of theevacuation process, LILCO has estimated a maximum of
5 minutes for the plant operator to assess the extent ofan accident from control room instrumentation, a maximum of 10 minutes for estimation of possible offsite
doses, and 5 minutes to notify local authorities, and thatthe entire LPZ could be cleared within 2 hours after anorder is given to begin notification for evacuation. Removal of people from any single 45" sector within the LPZ
could be completed in much shorter time..." (7NRC at
853).
I n TMI-2 SNRC9, the sequence of events is described
as: "Stated in an extremely simplified way, the sequenceof activities following an accident or incident, or othercause of radioactive release, would be as follows. The
occurrence of the event would be detected, and its
severity assessed, by means of instruments locatedonsite and monitored in the control room (and confirmed
and augmented by portable equipment).... Thereupon,
the applicants would notify first the State Council of Civil
Defense duty officer (who is available at all times) andthen (as necessary) the State Police, a nearby medical
center and NRC.... In the event of the most serious typeof incident, the occurrence would become known inseconds, and the duty officer would be notified within 5
minutes.... That officer in turn would notify the county
civil defense organization ... which is also manned without
i nterruption ... and the BRH duty officer. BRH would confirm the notification by recontacting the applicants..."(8NRC at 15).
21
But see 10, above: "The decision to initiate a protective action may be a complex process with the benefits oftaking the action being weighed against the risks andconstraints involved in taking the action. In addition, thedecision will likely be made under difficult emergency
conditions, probably with little detailed information available..." (p. 1.8). See also p.1.2.
However, the uncertainty touched upon here appears
to concern the amount of release rather than the natureof the event: "The amounts and types of radionuclides
available for release should be immediately calculable bysite personnel. What is actually being released to theenvironment can be estimated but may not be confirmedby some time after the incident. The magnitude andduration of the release may be estimated by site personnel from plant conditions or from knowledge of the typeof incident that has occurred. However, the estimate may

be highly uncertain and must be updated on the basis ofonsite and offsite monitoring observations and operational
status of engineered safeguards. If source term information is not available immediately, default values should beavailable from planning efforts. These values could bebased on accident scenarios from WASH-1400, designbasis accidents evaluated in the NRC safety evaluation
report for individual facilities, or other scenarios appropriate for a specific facility" (p. 1.9).

22WASH-1400 and Appendix G of Grimes-Bryan
study (note 70, below), are evaluations based on postul ated or defined scenarios. The examples given in theJamesport and TMI-2 cases in note 20 above also reflectvery rapid and well defined events. Similarly, all thecases identified in notes 10 and 11, above, are discussed
in terms of well defined events.
The MITRE Report 7618, discussed at note 83, below,
sets forth eight well defined scenarios as, "intended todemonstrate the full range of incidents to which NRC
might have to respond" (p. 1, Vol. II).
23

See note 10, above: "Nuclear facility operators havethe initial responsibility for accident assessment. Thisi ncludes prompt action necessary to evaluate publichealth and safety both onsite and offsite.... Ideally, thisnotification should occur as soon as conditions in thefacility are such that an impending accidental releasepotential exists. While such notification could lead tofalse alarms on rare occasions, they could also permit
more timely protective actions than postponing the notification until a release has occurred .... Immediately upon
becoming aware that an incident has occurred that may
result in exposure of the offsite population, a preliminary
evaluation should be made by the facility operator todetermine the nature and potential magnitude of thei ncident. This evaluation, if possible, should determine
potential exposure pathways, population at risk, and projected doses..." (p. 1.20).
However, the underpinning of the guidance on protective actions is projected dose (see EPA Manual of Protective Action Guides, referenced in NRC guidance in Reg.
Guide 1.101, NUREG-0396, and 43FR37473.) The guidance for projecting such doses tends to be in terms ofi nformation available from control room instrumentation( Reg.Guide 1.101, Annex A, 4.1.3, 4.1.4, 4.1.5; 1970 Guide,p. 4; NUREG-0396, p. 3) or other preplanned scenarios(e.g., EPA Manual Section 5). While these preplanned
relationships are extremely important, the relationshipbetween specific control room readings and projected
doses may not be valid for accident sequences not postulated. Yet there is no discussion of this limitation or the
potential implications for confusion in the event of an
accident different from those postulated.
This problem is exacerbated by conflicting approaches
to the making of dose projections for protective action
decisions. For example, one portion of the TMI Emergency Plan Procedures, 1670.4, calls for prompt calculation from control room instruments of projected doses
and spells out a procedure for making such calculations.
It indicates that these calculations are the basis of any(prompt) decision on emergency protective measures,with field measurements, when made, used to correct the
projected dose (Sec. 4.6.4). On the other hand, Procedure 1670.7, Sec. 4, and Procedure 1670.3, Sec. 4.1.5,
i ndicate that evacuation of the public off site is to be
based upon (and will therefore await) offsite measurements.
1 09 5

24

See Reg. Guide 1.101: "Although Federal agencies
can and will respond to emergencies arising from nuclear
power plants activities if necessary, such response
should be regarded primarily as supportive of, and not asa substitute for, responsible action by licensees and Stateand local governments. The development of an effective
i nterface between the licensee and the State and local
governments in radiological response planning is therefore necessary... " (pp. 1.102-2).
See also NUREG-75/111: "An additional emergency
measure for which facility operators have a primary
responsibility is accident assessment. This includes
prompt action to evaluate any potential risk to the publichealth and safety, both onsite and offsite, and timely
recommendations to State and local governments concerning protective measures" (p. 3).
See also note 70, below: "All action within such ashort timeframe must be taken by those with the best
i nformation, the best knowledge of the facility, and thebest chance to influence the outcome of sequence of
events-the onsite plant operating staff" (p. 10).
See also: note 9, above, p. 68C; and note 10, above,
pp. 1.20-1.21, and 5.9.
25

Compare this to Grimes-Bryan study (note 70,
below), at p. 12, and Appeal Board Decision TMI-2, 8NRC,
pp. 20-22.
26

See note 70, below, pp. 10-12. See also the memofrom Rusche to Volgenau dated May 26, 1976, quoted in
the discussion under text Subsection 2.a., of the "Function of NRC Response" in the 1975-1976 initial planning.
See also note 83, below: "Power reactors-personnel
are onsite at all times who are technically trained and wellqualified to help assess most problems" (Vol. 1, p. 7), and" The licensee has the responsibility for his facility and thepersons working there and would have the most thoroughknowledge of a problem and actions which might beunderway to alleviate it" (Vol. II, p. 10).

27
Stello dep., pp. 44-49. See also Mattson dep.,
October 17, 1979, pp. 81-84. Cf. Eisenhut dep., at137-141, 145, Mattson dep., October 17, 1979, pp.
200-207.
28

See Regulatory Guide 1.101: "This policy is based on
the recognition that State and local governments have thenecessary authority to implement protective measures forthe public in their jurisdictions. Although Federal agencies can and will respond to emergencies arising from
nuclear power plant activities if necessary, such response
should be regarded primarily as supportive of, and not asa substitute for, responsible action by licensees and Stateand local governments" (p. 1.101-2).
See also FRPPNE, Annex I: "This plan provides guidance to Federal agencies to assure that a coherent andcomprehensive approach to Federal response activities
to nuclear emergencies is developed. Most importantly, it
recognizes that, under our constitutional form of government, those emergencies, unless they occur in federally
controlled areas or involve federally owned material or
equipment, are in the first instance, a matter of concern
to State and local authority" (p. 1).
29

FRPPNE, Annex I, pp. 11-12.

Northem States Power Co. v. Minnesota, 447
F.2d1143 (8th Cir. 1971), aff. mem. 405 U.S.1035 (1972);
Pacific Legal Foundation et al. v. State Energy Resources
Conservation and Development Commission et al., Cir.
No. 78-711E (S.D. Cal. March 6, 1979) (on appeal).
30

Answer to question 1, Enclosure 1, from C. Kammerer, NRC, to M. Udall, Chairman, Subcommittee on
Energy and the Environment, Committee on Interior andInsular Affairs, U.S. House of Representatives, dated May
8, 1979, Hearings on Nuclear Regulatory Commission
Authorizations for Fiscal Year 1980, Before Committee on
Interior and Insular Affairs, House of Representatives,
96th Congress, 1st session, February 22 and March 2,
1979, pp. 502 et seq.
32
lnformation derived from Nucleonics, February 1961,
pp. 17-18; Nucleonics, December 1961, pp. 43-46; SL-1
Accident, Atomic Energy Commission Investigation Board
Report, printed by Joint Committee on Atomic Energy,
Cong. of U.S., 86th Cong., 1st Session., June 1961.
33
See note 32, above: "We suggest that the effectiveness of the Operations Office in conducting recovery andi nvestigatory operations may have been impaired by theearly presence of so many outside personnel. It is notedthat within 24 hours of the incident there were present an
AEC Commissioner, the General Manager, the Director of
the Operating Division and several other members of theDivision, the Board of Investigation and its consultants
and advisers, representatives from several other AEC
sites and several other Federal agencies, and the press"(P. X).
34
The management meeting included McCarthy,
Amorosi, Wilber, Jens, Olson, and Johnson. This groupconsisted of people who had long and close association
with the engineering design and development of the Fermi
reactor and were associated with its operation.
McCarthy had been Assistant General Manager of PRDC
for a number of years and, before that, had been head of
nuclear engineering for APDA. Amorosi had been thelong time technical director of APDA. Wilber was alicensed reactor operator and had long been associatedwith the Fermi project and with the design of its instrumentation and control systems.
The list of people at the meeting was taken from We
Almost Lost Detroit, John Fuller, Readers Digest Press, T.
Y. Crowell Company, New York, 1975, p. 202. Backgrounds taken from Fermi 1, New Age for Nuclear Power,
Alexanderson, Ed., American Nuclear Society, LaGrange
Park, III., 1979, Chapters 4, 5, 11 and Appendix C.
s

Id. at 230.

Information derived from Hearings before Joint Committee on Atomic Energy, U.S. Cong., on Browns Ferry
Nuclear Plant Fire, 94th Cong., 1st Sess., September 16,
1975.
37I
nformation derived from memorandum from Higginbotham and Thornburg, NRC, to Volgenau, NRC, dated
March 8, 1978.
36

In response to a GAO report critical of NRC efforts
to obtain better State and local emergency preparedness
around nuclear facilities, the NRC Executive Director
responded: "I would like to comment briefly on each of
the key conclusions of your report:"1. NRC should approve license applications fornuclear facilities only in States that have concurred-inplans. "NRC protects public health and safety by giving
primary consideration to site characteristics and design
features of nuclear facilities. Once we are satisfied thatthese meet an adequate measure of safety, we evaluate
the emergency plans for the facility. From this point ofview, State and local emergency plans provide an added
margin of protection for the public in the vicinity of a
38

1 096

nuclear facility in which we believe that an adequate
measure of safety already exists. The Commission's
li censing decision process is structured to take into
account a wide variety of standards and criteria in theevaluation of proposed or existing nuclear power plants
to the end that substantial conservatisms exist in designand operating safety margins. To the extent that proposed or existing plants fail to meet these standards,
NRC would not license them or permit them to continue
to operate. In this context, State and local plans while
related to the facilities undergoing the licensing process,and to applicant's emergency plans, are not essential indetermining whether the plant can be operated without
undue risk to public health and safety."
See also Report to Congress by the Controller General, "Areas Around Nuclear Facilities Should be Better
Prepared for Radiological Emergencies," EMD-78-110,
March 30, 1979. The response by the NRC Executive
Director for Operations is set forth as Appendix VII, pp.
67-77.
Similarly, see testimony of Chairman Hendrie in which
he outlined the various elements of the regulatory process that contribute to assurance of public health andsafety. The emphasis is on design considerations andthere is no mention of emergency planning. See oversight Hearing Before the Subcommittee on Energy andEnvironment, Committee on Interior and Insular Affairs,
House of Representatives on Reactor Safety Study
Review, 96th Cong., 1st Sess., February 26, 1979, pp. 90
et seq.
`*See Manual Chapter 0502 adopted May 4, 1976,
which was superseded by a revised Manual Chapter
0502 on February 6, 1978, in effect at the time of the TMI
accident. To distinguish between these two revisions, the1976 version will be referred to as the "initial plan" or"0502(1976)." The 1978 version will be referred to as the"current plan" or "0502(1978)."0502(1976), Sec. 02.
0502(1976),0502(1976), Sec. 032: The Director, IE,"Evaluates reports of incidents and determines and initiates the initial required response, including where
requesting
radiologicalassistanceappropriate,from ... (ERDA)....
"Advises the Commission ... and senior NRC management on questions connected with an incident relating tothe operational aspect of shutting down or placing
li censed facilities in a safe condition."
The Director of the Regional Office "initiates appropriresponse
actionsrequiredbycontingency
ateplans ....Investigators ... will be sent to the incident scene
if appropriate ... response actions may be raised or
lowered ... if ... information is obtained which warrants
such an action" (App. p. 1).
The IRACT "will direct and coordinate the initial actions
taken in response to Level I incidents which have particularly significant health and safety ... or public interest
aspects" (App. p. 2).
The Office of Inspection and Enforcement "Evaluates
reports ... to determine the initial response actions
required and initiates the response actions, including the
dispatch of inspectors to the scene when appropriate"p. 3).
( App.
420502(1976), Secs. 02, 032, 037, 0310, 0311, andApp.
pp. 1-5, 7.
430502(1976), Secs. 02, 032, 034, 035, 036, 037,
and App. p. 2.
40
41"The Commission and EDO are to be notified by the
Director of IE of the occurrence of incidents and are to beadvised by the Director of IE "on questions connectedwith an incident relating to the operational aspects ofshutting down or placing licensed facilities in a safe condition" (0502(1976)-032).
45
The NRC Manual did not specify the composition of
IRACT, but IE Manual Chapter 1300 identifies IRACT ascomposed of the Director and Deputy Director of IE andthe Directors of three IE Divisions-Reactor Inspection,
Materials Inspection, and Field Operations. IE Manual
Chapter 1300, p. 1300-2.
0502(1976), 032, App. p. 1-3.
470502(1976), 035, 036, and 046.
48
0502(1976), 035, 036. The Director of NMSS is
also given responsibilities for developing plans for security threats.
49
Although the IE Manual is dated December 11, 1975,
earlier than the May 4, 1976, date of the NRC Manual
Chapter, they were in process during the same period.
50 Unlike 0502(1978).
51
1 E Manual Chapter 1300, App. 1320.
520502(1976), App. p. 7.
53
1E Manual Chapter 1300, App. p. 1300-All-1.
54
1 E Manual Chapter 1310.
55
1 E Manual Chapter 1300, App. 1300; IE Manual
Chapter 1310.
58
0502(1976), App. p. 5; IE Manual Chapter 1310,
Chapter 1320, App. 1320, Enclosure 2.
57
See note 41, above.
58
0502(1976), App. p. 1.
59
1 E Manual 1310-Al-1.
eOThe Regional Plan, Davis Ex. 5012, was developed in
1977. It is similar to and apparently based in large measure on IE Manual Chapter 1300.

Regional Plan, p. 15. Onsite inspectors are also
given radiological assistance and lifesaving responsibilities discussed below.
82
1 E Manual Chapter 1300, p. 1300-1; Regional Plan, p.
2.
e3 An early draft of the Initial Plan, attached to a memo
dated June 30, 1975, from L. Higginbotham to J. G. Davis,
et al., specifically would have disclaimed authority toi ntervene in a licensee's actions in response to an emergency. "The licensee has primary responsibility forassuring safe conditions in his operation ... and for taking
preplanned actions to protect health and safety ... fromthe consequences of incidents which may occur directly
as a result of his operation. The NRC will respond to signific ant incidents and emergencies which involve licensees by sending its personnel to the scene; however, thearrival and presence of NRC personnel at the scene does
not relieve the licensee of his responsibility. NRC personnel have no authority to direct, nor assist in the directionof, the licensee's actions or operations."
B. Rusche, then Director of NRR, commenting on thissection, stated in a memo dated July 24, 1975, to D.
Knuth: "The first paragraph should be qualified somewhat
to reflect our responsibilities and authority under our
regulations, the Atomic Energy Act, and Energy Reorganization Act. In particular, the term 'responsible authorities'
needs definition and clarification. NRC's authority toissue orders for the protection of the public should be

109 7

discussed here and also in Section OXXX-04, 031g. on
pp. 4-5."
A subsequent version of the draft, in a memo from
Higginbotham to Carter, et al., dated October, 1975,
appears without this disclaimer, but also without reference to the NRC's authority to issue orders.
84
An undated letter signed for B. Grier, Director of
Region I, contained as part of the Met Ed Emergency Planfor the Three Mile Island reactor, states: "The primaryrole of the NRC during a radiation emergency is that of
conducting investigative activities associated with thei ncident and verifying that emergency plans have been
implemented and proper agencies notified. In addition,
however, if NRC personnel are dispatched to the scene,
they will, as needed, assist in coordination with theEnergy Research and Development Administration Radiological Assistance Team and provide to State and local
agencies advisory assistance associated with investigating and assessing hazards to the public."
Similarly, in 1976, N. Moseley, then Director of RegionII, in a memo to D. Thompson, dated September 3, 1976,
discussing certain information needed from the regional
offices to support the Headquarters Plan, stated: "I question the necessity for this detail in information since itstrongly implies that we envision managing the incident.
We are not prepared in any way to manage incidents. I
strongly doubt that we could prepare ourselves tomanage large incidents. A significant manpower commitment would be needed. Further, a detailed knowledge ofeach facility much in excess of that we now have isrequired for effective incident management. We have no
mechanism to obtain rapid information about the incident
upon which to base operational decisions."
Subsequently, after the Three Mile Island accident, R.
Engelken, Director of Region V, in a memo to B. Grier,dated May 21, 1979, discussed his concerns over what
appeared to be the sharing of responsibility for plant
operations between the NRC and the licensee some three
weeks after the initial accident during efforts to achieve along term stabilization of the cooling mode, stated: "Thisarrangement apparently in effect since early after NRC
arrived at the site in force, conflicted rather sharply within
NRC's longstanding philosophy of operations, i.e., that theli censee has the primary responsibility for the safety ofoperations and the NRC assures that the licensee ismeeting that responsibility."
He goes on to say: "The emergency mode of operations and its lack of definition of how responsibility andauthority were to be shared during that emergency mode,
left it pretty much to the man in charge to decide for himself just what his authority and responsibility were. While
this may have been unavoidable during the early NRC
response to the incident, I felt that by the time that I
arrived at the site there should have been better definitionof how the NRC was to interface with the licensee during
recovery operations."
65

He also states: "We kid ourselves to think we cando much in less than one or a few hours ...."
ss"Recommendations Related to Browns Ferry Fire,"
Report by Special Review Group, USNRC, NUREG-0050,
February 1976.
67Id. at7.

saId. at 58.

"There were criticisms of TVA's failure to use water
to extinguish the fire for some seven hours. See Hear109 8

i ngs on Browns Ferry Nuclear Plant Fire (note 36, above),pp. 13, 45, 817. However, the fire was extinguished at
7:45 p.m., before the NRC inspectors arrived.
70
NRC Incident Response, B. K. Grimes and S. E.
Bryan, Draft $j2, dated July 23, 1976, Grimes Exhibit
5029;
See Grimes dep. at p. 21.
71/d. at 2.
72
Id. at 9.
73
kf. at 10-12: "All action within such a shorttimeframe must be taken by those with the best information, the best knowledge of the facility, and the best
chance to influence the outcome of a sequence of
events-the onsite plant operating staff. Even if it werepossible to arrive at specific action plans for response toa large number of accident scenarios which would
theoretically allow remote direction of an incident, thebest use of these action plans would be to make themavailable to all operating plants for incorporating into theiremergency procedures.
"Despite the impracticality of obtaining and adequately
evaluating plant and site information immediately after initiation of an incident, there are a number of scenarios
where action taken many hours after initiation of anincident are of high significance.... Even in these cases,
however, an intimate knowledge of the facility by theoperating staff would have to be combined with any additional evaluative resources that the IMC may be able tobring to bear to implement actions within the facility. The
IMC plant-related activities are therefore expected to beat most advisory in nature. It would be an extremely
unusual situation where directives would need to bei ssued with regard to specific plant actions in response toi ncidents. A somewhat better case can be made for IMC
direction of offsite actions, mainly because of the additional time available.... Even for offsite actions, however,the IMC role would be much more likely to be advisory
than directive."
The IMC referred to in the quote is the "IncidentManagement Center," the location to be used by NRC
Headquarters personnel in connection with Headquarters
i ncident response. The name was later changed to the"Incident
Response Center," or IRC.
74
Grimes, dep., p. 27; Thornburg dep. p., 59.
75
Grimes, dep., pp. 23, 27; Thomburg dep., pp.
46-48,52,53,55.
76
Grimes-Bryan Study, Appendix A.
77
Grimes-Bryan Study, p. 14.
78Id. at 16.
79
Id. at 19.
Bold. at 23-25.
B
bd. at 27.
82Memo, Cobb, NRC, to Halman, NRC, dated June 8,
1976. Initially, the proposed contract scope was quite
broad, encompassing as part of its purpose to define the"command control and communication procedures for
managing incidents." It mentioned as a policy issue to beconsidered, "the extent of NRC's responsibility to' manage' a licensee incident...." Subsequently, theplanned scope of work was reduced to identifying communication relationships and developing alternative command and control concepts (see memo, Thornburg toHalman, dated September 23, 1976). The contract was
executed on March 9, 1977 (NRC-05-77-044), and has
been modified to add tasks from time to time, including

gram," and a three-part Appendix thereto, an "NRC Headquarters Incident Response Plan" which incorporates
Manual Chapter 0502 and its Appendix; the Headquarters
Response Plan also incorporates the Incident Response
Procedure of the IE Division of Reactor Operations
I nspection. They are collectively identified as Davis Exhibit 5011. The Manual Chapter basically outlines theoverall objectives and the overall organization. The
Headquarters Plan provides certain duty rosters, notification lists, and some operating procedures. It also outlines
certain "National Level Emergency Procedures" for carryi ng out agency functions in National emergencies. The
Division of Reactor Operations Inspection Procedure provides specific duty assignments for members of that Division with some operating procedures for such personnel.
950502(1978), App. pp. 7, 9, 11. The Plan also creates,for safeguards threats, an Information Assessment Teamto assess the seriousness of threats (pp. 7, 14).
960502(1978), App. pp. 7, 8, 9.
97
1ts composition is not specified, but all Division
Directors are directed to provide IRACT support staff if
called upon to do so by EMT or IRACT 0502(1978), App.
p. 5. The initial duties of the IRACT Director include
selection of "a nucleus of staff members for IRACT support staff" (NRC Headquarters Plan, Sec. 3.5). In practice, this amounts to calling Division Directors or Assistant
Directors to identify the kinds of backgrounds needed.
The specific personnel are selected by the Division Director 98
or Assistant Director.
0502(1978), App. pp. 11-13
99
Such procedures are called for by 0502(1978), App.
p. 14.

the development and conduct of tests of the incident
response systems and the survey and specification ofequipment. (See, for example, "Request for Procurement," OIE-77-044 6/30/78; Amendment 4 Contract
OIE-77-044 5/11/78). Additional tasks were under discussion toward the end of 1978 and in early 1979, including that of providing certain advice to states and a studyof the psychological aspects of crisis management (draftof memo, Himes, MITRE Corp., to Ryan, NRC, dated
October 12, 1978; letter, E. Stewart to B. Weiss, NRC,
dated February 28, 1979).
83
MITRE Technical Report 7618, in two volumes, Com-ment, Himes, Lopez, Sandy, November 1977.

munications and Control to Support Incident Manage84id., Vol. I, p. 13; See also Vol. II., p. 16.
85Ad., Vol. I, p. 14, and Vol. II, p. 18.
1d., Vol. I, p. 14; see also Vol. II, p. 21.
87
1d., Vol. I, p. 15; see also: Letter, Jordan, NRC, toSanders, MITRE Corp., dated July 20, 1977.
"The report discussion, Vol. I, starts with a paraphrase of the statement from the Browns Ferry Fire Special Review Group Report quoted in the text: "(I]t is theli censee's responsibility to operate safely within the
NRC's regulatory program and the NRC's responsibility toassure that he does so" (p. 5). Then, as if it followed afortiori, the report states: "When an incident occurs the
NRC is ultimately responsible for:86

Minimizing the public risk by assuring that the incident isterminated with as little damage and as few subsequent
problems as possible.
Disseminating factual information in the proper context tothe public and to official bodies.
Preserving adequate information for later review, education and feedback into the regulatory process.

100

o NRC Headquarters Plan, Sec. 4.4.

"While any of these functions may be partiallydelegated to the licensee, the NRC must continually
evaluate the licensee's response and ensure that thefunctions are being property executed."
This is in contrast to the position expressed in thedraft report dated June 10, 1977 (MITRE Working Paper
WP 12413:"An incident requires action to mitigate its consequences, investigation to discover its cause, and dissemination of information to the public (and other authorities).
These latter two functions are the sole responsibility of
the NRC, and no agency is uniquely charged with thefirst"(p. 6).
89
MITRE Report, Vol. I, p. 5.
90
1d., Vol. I, pp. x, 22; Vol. II, pp. 12, 13, 25; Draft WP
12413, p. 22.
91
14., Vol. I, pp. x, xi, 22; Vol. 11, pp. 14, 22, 25.

Draft Report WP 12413, p. 23. The final report has
similar but briefer expression; see MITRE Report, Vol. I, p.
10.
93MITRE Report, Vol. II, p. 20; also Vol. I, p. 14. Thei mpact of this point tends to be softened by the belief
reflected in the report that, "The licensee has the responsibility for his facility and the persons working there andwould have the most thorough knowledge of a problem
and actions which might be underway to alleviate it" (Vol.
II, p. 10).
"The Plan consists of a set of documents, principally
NRC Manual Chapter 0502, "NRC Incident Response Pro-

0502(1978), App. 0502, p. 4.

1010502(1978), App. 0502, p. 15.
1 20502(1978), App. p. 8.
0502(1978), App. p.19.
10505020978), App. P. 7.
1060502 (1978), Sec. 044: The EMT is "responsible
for ... making decisions, and managing NRC's response toaccidents." 0502(1978), App. p. 7: The EMT "makes
major decisions affecting NRC's response actions; IRACT
executes EMT decisions by directing activities of IRACT
support staff...." 0502(1978), App. pp. 10, 11: EMT" Makes major decisions affecting NRC's response
actions." IRACT "Directs action of IRACT Support Staff
to implement EMT decisions..." and "Performs actions
required by IRACT Implementing Procedures in order tocarry out information, evaluation, assistance direction andcoordination functions." (See also NRC Headquarters
Plan, 4.2.2.1.)
103
104

107

See NRC Headquarters Plan, figures follow Sec.
3.6.4.
1 8
o NRC Headquarters Plan, Secs. 4.1.1, 4.2.1, and 4.2.3.

92

109

NRC Headquarters Plan, Sec. 4.2.1.

Memo, B. Rusche, Director, Office of NRR, and E.
Volgenau, Director, Office of IE, to L. Gossick, dated
March 21,1977.
110"'See discussion of 1975-1976 Initial Planning in text
Subsection 2.a.
112
113

109 9

Moseley dep., September, 25, 1979, pp. 10-30.

Grier dep., October 12,1979, pp. 3-5.

T4
The affected branch chiefs (Reactor Incident, Radiological Incident, and Security Incident) are specified.
They are to act as Coordinator of the Regional Incident
Response Center. The Emergency Planning Coordinatorserves as data recorder, and other identified officials
serve specified roles. It also appears that all branchchiefs and section leaders are to function as members of
RIRACT as needed. Regional Plan, pp. 10, 12,19, IRIP 1-2,
I RIP 2-1, IRIP 3-1.
115

Regional Plan, pp. 3, 5, 11, 19, IRIP-6.

Regional Plan, p. 10.
Regional Plan, p. 10; but usually the leader is to be
the principal or resident inspector, pp. 3, 11, IRIP 6-1.
117

"BRegional Plan, p. 9.

" 9 Regional Plan, pp.1, 2, 3, 5,11,15, IRIP 6-1.
120
121

Regional Plan, pp. 2, 11, IRIP 6-1.

Regional Plan, p. 11, IRIP 6-1.

122These are in the portions identified as IRIP, SP, andAppendices.
123 Regional Plan, Appendix D.
124 Regional Plan, p. 17.
125

Regional Plan: "The Regional staff, supplemented
by consultants and other federal agencies... is qualified
to perform all actions necessary to implement thisIncident Response Man..." (p. 9).

"Inspectors will be sent to the scene of incidents ... toassure that actions are being taken to protect people... "(p. 1).
"The Regional Office will provide radiological assistance to licensees and other agencies.... In matters of lifeand death or those which directly affect the public healthand safety, radiological responsibilities will supersede
normal regulatory functions" (p. 1).
"The Region I Office ... objectives... are to: Establish
the nature, extent and particulars of the incident....
Evaluate the licensee's actions to correct problems ... toassure safe conditions.... Determine if adequate protective and corrective actions are being taken..." (p. 1).
"OIT members... Determine the magnitude of the
problem and the hazards to the public..." (p. IRIP 6-3).
1260502(1978), App. pp. 11, 12.
127
Regional Plan IRIP 6-1; see the guidance as to how
to perform investigations, pp. IRIP 6-4 to 6-6.
128
Regional Plan, pp. 1, IRIP 6-1, 6-3.
129
Regional Plan, pp. 1, IRIP 6-1.
13
ORegional Plan, pp. 1, IRIP 6-3, 6-7.
131Regional Plan, p. 15.
132
AIso, by not mentioning this situation again, the plan
provides no picture of what the onsite inspector is to do
i n such an event, other than that he no longer needs to"avoid being directly involved in directing or ordering
actions by the licensee and other agencies...."

1100

APPENDIX 111.2
DEPLOYMENT OF NRC PERSONNEL
AND MANAGEMENT STRUCTURE

This appendix contains a detailed description of
the deployment of NRC staff in response to the TMI
emergency and the changing emergency management structures under which they operated. The
material presented covers the first 3 days of theemergency, March 28 through March 30,1979. The
description is subdivided to cover activities at thesite, at the NRC Headquarters, and at the NRC
Region I office (RO:I), in the following sequence.

On SiteMarch 28, 1979-The first onsite inspection team(OM departed the NRC's Region I office in an emergency vehicle and arrived on site at the TMI Nuclear
Power Plant by 10:15 a.m. Included in this team
were five RO:I inspectors: Donald R. Neely, Team
Leader (TL) and Lead Health Physicist (H/P);""2,3
Charles O. Gallina, Investigator (I) and Emergency
Planning Officer (EPO); 4 James C. Higgins, Operations Reactor Inspector (ORI); 5 Karl E. Plumlee, H/P;and Ronald L. Nimitz, H/P. 6
I nitially, all five members of the first Region I contingent on site reported to the Shift Supervisor's office in the TMI-1 (U 1) Control Room, 7 which had
been designated the Emergency Control Station(ECS) by the plant management.s' 9 From there,
under the direction of the team leader, members of
the OIT deployed and performed various duties
around the plant.10" 11

March 28, 1979

On SiteHeadquarters Incident Response Center
Region I IRC

March 29, 1979

On siteHeadquarters IRC

March 30, 1979
On site110 1

Neely, with assistance from Higgins, 12 went to the
TMI-2 (U 2) Control Room, where they collected
data and attempted to evaluate the situation.
13
with assistance from
Staying in U 1, Gallina,
Nimitz and Plumlee, established a Command Post
( CP) in the Shift Supervisor's office. From there
they collected utility data and received updated information from U 2. Through a mutual agreementwith Metropolitan Edison (Met Ed) personnel in U 1,
they took over communications previously established by Met Ed, an open telephone line between
RO:I and U 1 and communicated their findings to the
I RC.
Soon after this system of communication was established, and as a result of a direct request from
George Smith of the RO:I IRC Incident Response
Action Coordination Team (IRACT) management at
the Incident Response Center (IRC), Plumlee departed U 1 and went outside to monitor on
14 site andaround the exterior of the reactor facility.
Within an hour, a second team departed RO:I in a
private vehicle and arrived on site. Included in thiscar were two RO:I Inspection and Enforcement (IE)
i nspectors: Walter F. Baunack, Operations Reactor
I nspector, and Raymond H. Smith, Investigator.
Upon arrival at the site, the second RO:I contingent (Smith and Baunack) reported to the TMI-1
CP. Shortly after their arrival, because of high airborne activity in the Control Room and the nonavail ability of respirators, they departed the plant for theObservation Center, where they remained until latethat afternoon. 15
By 5:00 p.m.
they were back on site in TMI-2
16,17
with Higgins.
There, Smith assumed the role ofcommunicator and manned an open telephone line
between U 2 and the RO:I IRC, thereby establishinga CP in U 2. Like their counterparts in the U 1 CID,
they observed the situation, collected data and other available information, and communicated theirfindings to the RO:I IRC.
By early evening, with two CPs in operation at
the TMI site, the U 1 CP became the center for radiological data collected and communicated to the
RO:I IRC, while the U 2 CID became the focal point
for all operations-related data collected and communicated to18,19
the Headquarters (HQ) IRC throughthe RO:I IRC.
Of the first seven OIT members, Higgins andBaunack were the only two operations-oriented inspectors. Nimitz, Neely, and Plumlee were all Health
Physicists, and Smith and Gallina, even though assigned as investigators, also had backgrounds as
health physicists. 20,21
By as early as 12:00 noon the NRC organization
on site was in place, and the individual roles were

defined. App. Figure III-1 shows the organizational
structure of the NRC presence on site that remainedin place until early in the evening.
As a function of time, the following schedule reflects the deployment of NRC personnel throughout
the plant and off site:
11:00 a.m.-12:00 Noon
U2

D. Neely, TL, Lead H/P
J. Higgins, ORI
U 1 ECS

C. Gallina, OIT EPO, I, U 1 TL
R. Nimitz, H/P
W. Baunack, RI
R. Smith, I
Onsite Outside Monitoring
K. Plumlee, H/P

By 1:00 p.m., William Raymond, Operations Reactor Inspector, was dispatched from the RO:I IRC andarrived on site by late that afternoon. There heprepared to go on shift later that night to relieve the
NRC Rls who worked that day.
12:00 Noon-5:00 p.m.
U2

D. Neely, TL, H/P
J. Higgins, RI
Observation Center
W. Baunack, RI
R. Smith, I
W. Raymond, RI
Ui

C. Gallina, EPO, I
R. Nimitz, H/P

Offsite Monitoring
K. Plumlee, H/P
5:00 p.m.
U2

D. Neely, H/P
J. Higgins, RI
110 2

*Dr. Galling was the Emergency Planning Officer (EPO) and investigator assigned to the initial OIT. As such, he assumed the job of making sure the team arrived onsite withthe proper equipment, and that the emergency aspects of the plan operated smoothly. Subsequent to the team leader's departure from U 1 to U 2, Gallic assumed theduties of team leader for Unit 1 22

APP. FIGURE III-1. NRC Onsite Organization on March 28, 1979

W. Baunack, RI
R. Smith, I
Observation Center
W. Raymond, RI
U1

C. Gallina, I
R. Nimitz, H/P
Offsite Monitoring
K. Plumlee, H/P

Early in the evening, John Stohr, Chief, Environmental and Special Projects Section, and James
Kottan, Radiation Specialist, arrived at the Observation Center in the RO:I radiological monitoring van.
They had been called back by the RO:I IRC
management from an inspection at the Millstone site
i n Connecticut. After a quick briefing at RO:I, they
departed for TMI.

On his arrival, Stohr was the senior NRC official
on site and as such took charge of the OIT. In thiscapacity, he contacted the team members, checkedon the organization and placement of the team, put
the mobile laboratory into operation,and established23
communications with the RO:I IRC.
Later that evening, Richard Keimig, Chief, Reactor
Operations Section, arrived on site and shared the
management responsibilities with Stohr, taking
charge of the operations side of the OFT. Keimig
was now the senior NRC person
on site and as
24-27
such also took charge of the OIT.
By the end of the day a formal organization andmanagement structure had evolved. The NRC'spresence on site had grown from the initial five inspectors to nine inspectors (two investigators, threeoperations, four health physics), two managers (oneoperations and one health physics), and a mobile laboratory. All personnel and equipment were from
Region I; a total of 11 NRC personnel were at TMI.
App. Figure 111-2 shows NRC's organization onsite and in place Wednesday night through Thursday afternoon.
1103

'Reported to Keimiy; Maintained the Lad in the HIP arm; Communicated with RO:I I RC Directly.

APP. FIGURE 111-2. Management and Organization of NRC Force, End of Day,
March 28, 1979

1104

Deployment of NRC personnel on site and off siteat the end of Wednesday, March 28, 1979, was asfollows:
Observation Center

Harold Denton, Director of NRR, who was planning to leave town, originally sent Case to the EMT.
It was not until late in the afternoon that Denton arrived at the HQ IRC.
T RACT

J. Stohr, Radiological TL
R. Keimig, Operations TLWith the formation of the EMT, the Incident
Response Action Coordination Team (IRACT) started to take shape. Under the direction of Norman C.
Moseley, Director (D), Division of Reactor Operations Inspection (DROI), IE, the IRACT drew substantially on NRC HQ staff, principally from IE and
NRR, and grew rapidly. On hand at the outset was
Victor Stello, Director, Division of Operating Reactors (DOR), NRR.
Eventually, eight additional members of NRC's top
I E-NRR management became part of the team. Included were: Dudley Thompson, Executive Officer
for Operations (EOO), IE; Harold D. Thornburg,
Director, Division of Reactor Construction Inspection( DRCI), IE; James H. Sniezek, Director, Division of
Fuel Facilities and Materials Safety Inspection( DFFMS), IE; Elbert M. Howard, Director, Division of
Safeguards Inspection (DSI), IE; Samuel E. Bryan,
Assistant Director (AD) for Field Coordination, IE;
Leo B. Higginbotham, Jr., Assistant Director for
DFFMS, IE; Edward L. Jordan, Assistant Director forTechnical Programs, IE; and Roger W. Woodruff,
Senior Reactor Inspection Specialist, IE.
With the EMT and IRACT in place, the infrastructure of the HQ response was formed. The following
chart and schedule reflects the relationship between
the two groups, and the people involved in them.

Mobile Lab

J. Kottan, Radiation Specialist
UIECS

C. Gallina, EPO, I
U2

D. Neely, Lead H/P
J. Higgins, RI
W. Baunack, RI
R. Smith, I
W. Raymond, RI
Offsite Monitoring
K. Plumlee, H/P
R. Nimitz, H/P

Headquarters Incident Response Center, Bethesda,
MarylandMarch 28, 1979- Early in the morning, the NRC
Headquarters Executive Management Team (EMT)
was notified of the accident at TMI and rapidly started to assemble in the Incident Response Center(I RC) at Bethesda, Md. Concurrently, the emergency management procedures in the Bethesda NRC
HQ IRC, also known as the Operations Center (OC),were activated.
I n accordance with the criteria (Appendix 0502 of
the NRC Manual), groups from NRC HQ would
respond through the IRC.

EMT

EMT

L. V. Gossick, Director, EMT, EDO
H. R. Denton, Director, NRR
E. G. Case, Deputy Director, NRR
J. G. Davis, Acting Director, IE

Pursuant to the criteria stated, the EMT formed.
According to the stipulations within its charter, theEMT would be the principal entity exercising the
NRC's authority in the case of an accident.
I nitially, the team consisted of Lee V. Gossick,Executive Director for Operations (EDO); Edson G.
Case, Deputy Director, Office of Nuclear Reactor
Regulation (NRR); and John G. Davis, Acting Director, Office of Inspection and Enforcement (IE).

IRA CT

N. C. Moseley, Director, IRACT, DROI, IE
V. Stello, Director, DOR, NRR
H. D. Thornburg, DRCI, IE
110 5

E. M. Howard, DSI, IE
J. H. Sniezek, D/DFFMS, IE
L. B. Higginbotham, A/D DFFMS, IE
D. Thompson, EOO, IE
S. E. Bryan, A/D Field Coordination, IE
E. L. Jordan, A/D Technical Programs, IE
R. W. Woodruff, Senior Reactor Inspection Specialist, IE
Balance of Staff

EMT Support

Forming as rapidly as the EMT and IRACT, other
NRC groups were assembled to assist with the accident.
Reporting to the HQ IRC to support the EMT fromthe Office of Public Affairs came J. J. Fouchard,
Director, and F. Ingram, Assistant to the Director.
From the Office of State Programs came: R. G.
Ryan, Director; R. T. Jaske, Technical Advisor to the
Director; B. DeFayette, Reactor Safety Engineering(Emergency Planning); and H. Gaut, Emergency
Preparedness Specialist. From the Office of International Programs came R. S. Senseney, International Programs Assistant. From the Antitrust andI ndemnity Group within NRR came J. D. Saltzman,
Chief, and Ira P. Dinitz, Indemnity Specialist. Arrivingfrom the Division of Operating Reactors, NRR: D. K.
Davis, Chief, Systematic Evaluation Program Branch( SEPB).
Meanwhile, at RO:V, R. F. Fish, Jr., Radiation
Specialist, and J. Hanchett, Public Affairs Officer, together served a public affairs role, as did Karl Abraham, Public Affairs Officer in RO:I.
Figure 111-3 shows the relationship of the EMT
support groups with the EMT and IRACT:The following schedule reflects the NRC personnel as a function of the emergency response, andtheir relationship with the EMT support staff, EMT,
and IRACT.
EMT

L. V. Gossick, Director, EMT, and EDO
H. R. Denton, Director, NRR
E. G. Case, Deputy Director, NRR
J. G. Davis, Acting Director, IE
Liaison/Coordinator

B. DeFayette, Reactor Safety Engineer (Emergency
Planning)
H. Gaut, Emergency Preparedness Specialist
D. Davis, Chief, SEPB, NRR

Public Affairs HQ

J. Fouchard, Director, PA
F. Ingram, Assistant to the Director, PA
R. Ryan, Director, SP
R. Jaske, Technical Advisor to SP Director
R. Senseney, International Programs Assistant, IP

ROJ

K. Abraham, PA Officer

RO: V

R. Fish, Radiation Specialist
J. Hanchett, PA Officer

APP. FIGURE 111-3. EMT and Support Groups
1106

IRACT Support

John I. Riesland, Howard A. Wilber, and G. Klingler;and Reactor Inspection Specialist James C. Stone.
James Gagliardo, Inspection Specialist, Performance Appraisal Team, IE, from RO:IV, was in HQ at
the time of the accident and contributed his skills tothe emergency.
By the end of March 28, the HO IRC had evolved,
and HQ NRC had 71 people directly involved fromthroughout the agency. From NRR there were 24
people; from IE 35 people; from other groups, 12
people.
Figure 4 and the following schedule of NRC personnel reflects the HQ incident response as an organization and identifies the NRC personnel that
responded, their areas of expertise, and the functions they performed.

During Wednesday, personnel resources fromwithin NRC responded to the IRC to assist the
IRACT in its mission.
From IE, for operations support, came: B. Weiss,
Senior Technical Operations Specialist; R. Paulus,
Senior Health Physicist; J. Hegner, Incident andOperations Coordinator Intern; W. Ward, Investigation Specialist; S. Morales, Engineering Aide (CoOp); T. W. Brockett, Jr., and G. Barber, Enforcement
Specialists; and K. Jackson and C. Deliso, Secretaries.
From the Division of Operating Reactors, NRR,
came: Darrell Eisenhut, Deputy Director; Brian
Grimes, A/D for Engineering and Projects; George
Knighton, Chief, Environmental Evaluation Branch; S.
Block, Senior Health Physicist, EEB; D. Davis, Chief,
Systems Evaluation Program Branch; Lake Barrett,Environmental Evaluation Branch; P. Shemanski,
Senior Systems Analyst; M. Mendonca, Reactor Engineer; T. Marsh, Nuclear Engineer; E. Wenzinger,
and J. Bland, Radiological Engineer.
From the Division of Systems Safety, NRR, came:
Leo Beltracchi, Principal Reactor Engineer (Instrumentation); Reactor Engineers F. Orr and E. Throm;
and Senior Reactor Engineer, J. Watt.
From the Division of Site Safety and Environmental Analysis, NRR, came: R. P. Denise, A/D for Site
Technology; L. Soffer, Section Leader, Accident
Analysis Branch; Robert E. Jackson, Jr., Section
Leader, Geology-Seismology Section; Reactor
Safety Engineer J. A. Martin; and Geophysicist
Phyllis A. Sobel.
From the Division of Project Management, NRR,
came H. Silver, Senior Project Manager for Light
Water Reactors.
From the Division of Reactor Safety Research,
Office of Nuclear Regulatory Research, came Thomas Murley.
From the Division of Fuel Facility and Materials
Safety Inspection, IE, came Senior H/P L. Cunningham and H/P L. Cohen.
From the Executive Office for Management andAnalysis, IE, came Steven Showe, Chief, PWR Technology Section; and Nuclear Engineers (Instructors)
Paul Harmon, Paul Bemis, and Arthur Oxfurth.
From the Division of Reactor Operations Inspection, IE, came Nuclear Engineer Donald C. Kirkpatrick.
From the Division of Reactor Construction Inspection, IE, came Kermit W. Whitt, Chief, Performance Appraisal Branch.
From the Division of Reactor Operations Inspection, IE, came Senior Reactor Inspection Specialists

Personnel Deployment
End of 3/28/79
EMT

H. Denton
E. CaseL. Gossick
J. Davis
IRA CT

N. C. Moseley, DROI, IE
H. D. Thornburg, DROI, IE
E. M. Howard, DSI, IE
J. H. Sniezek, DFFMS, IE
V. Stello, DOR, NRR
S. E. Bryan, IE
E. L. Jordan, DROI IE
L. Higginbotham, DFFMSI, IE
R. W. Woodruff, IE
D. Thompson, IE
EMT-indemnity Advisory

J. Saltzman, AIG
I. Dinitz, AIG

EMT-Public Affairs

J. J. Fouchard, PA
F. Ingram, PA
K. Abraham, RO:I
R. T. Jaske, SP
R. G. Ryan, SP
R. S. Senseney, IP

110 7

APP. FIGURE 1114. Management Organization and Structure, End of Day,
March 28, 1979, at HQ, IRC

H. A. Wilber, Senior Reactor Inspection Specialist, IE
J. Stone, IE
G. Klingler, IE
J. Gagliardo, IE, RO:V

RO: V

J. G. HanchettR. FishEMT-Liaison

Analysis-Technical Support

B. DeFayette, SP
H. Gaut, SP
D. K. Davis, NRR

E. Throm, DSS, NRR
T. E. Murley, RSR, RES
J. J. Watt, Senior Reactor Engineer, DSS, NRR
R. P. Denise, DSE, NRR
R. E. Jackson, DSE, NRR
P. A. Sobel, DSE, NRR
T. Marsh, Nuclear Engineer, NRR
A. Oxfurth, Nuclear Engineer, Instructor, IE
P. Shemanski, Senior Engineering Systems Analyst,
NRR, DOR, PSYB
M. M. Mendonca, NRR, DOR
F. Orr, DSS, NRR
E. C. Wenzinger, NRR, DOR

IRACT.• Operations Support Staff
B. H. Weiss
R. C. Paulus
J. Hegner
W. Ward
S. Morales
T. Brockett
G. Barber
C. Deliso
K. Jackson
D. Eisenhut

IRACT Plant Systems Effects GroupJ. A. Beltracchi, DSS, NRR
H. Silver, DPM, NRR
D. Kirkpatrick, Nuclear Engineer, IE
S. Showe, Nuclear Engineer, IE

IRACT.• Communications

K. W. Whitt, Chief, Performance Appraisal, IE
J. I. Riesland, IE
110 8

P. Harmon, Nuclear Engineer, IE
P. Bemis, Nuclear Engineer, IE
D. Davis, Chief, Systems Evaluation
Branch, NRR, DOR

RO:I office from the TMI nuclear power plant notifyi ng the NRC of the incident at TMI-2. Based on thenature of the call and the substance of the conversation, the NRC RO:I Incident Response Center (alsoknown as the RO:I Operations Center) was activated.
George Smith, Chief, Fuel Facility and Materials
Safety (FFMS) Branch, RO:I, assumed the leadership and directed the activities of the RO:I Operations Center and the Incident Response Action
Coordination Team (RO:I TRACT) within the Center.
Assisting Smith, and serving as a member of the
RO:I IRACT, was Eldon Brunner, Chief, Reactor
Operations and Nuclear Support (RONS) Branch.
Overseeing and managing the response activities
was the RO:I top management: Boyce Grier, Director, RO:I, and James Allen, Deputy Director, RO:I.
By virtue of their authority to act during an emergency, and under their direction, the basic structureof the RO:I response was formed.
The onsite inspection team (OM was assembled
and dispatched to the site to gather information andrelay it to RO:I. Concurrently, a command post
within the RO:I IRC was set up at RO:I and mannedwith round-the-clock staffing. A system of communications was established between the site and
RO:I.
In summary, the following chart and schedule ofpersonnel reflects the early RO:I response.

Program

IRA CT: Radiological and Environmental Effects
Group

J. A. Martin, Reactor Safety Engineer, DSE, NRR
L. Soffer, Section Leader, Accident Analysis Branch,
DSE, NRR
L. Barrett, DOR, EEB, NRR
J. Bland, DOR, EEB, NRR
G. Knighton, Chief, EEB, NRR
S. Block, EEB, NRR
B. Grimes, AD E&P, NRR, DOR
L. Cunningham, Senior H/P, IE
L. Cohen, H/P, IE
Commission

On March 28, 1979, the Chairman of the agency,
Dr. Joseph Hendrie, was not initially available. In his
absence, Commissioner Victor Gilinsky acted in his
stead. Throughout the day, individual Commissioners and staff members of the Commission tracked
the events closely and visited the IRC in Bethesda,
Md. From the Commission at the IRC for periods
throughout the day were: John Ahearne, Commissioner; Peter Bradford, Commissioner; J. Guibert,
Technical Assistant to Commissioner Richard Kennedy; Hugh Thompson, Technical Assistant to Commissioner Peter Bradford; and Vickie Harding, Legal
Assistant to Commissioner John Ahearne.
The following schedule of personnel and App.
Figure 111-5 reflect the Commission involvement androle as it related to the emergency response on
March 28,1979.
Commissioners

J. Hendrie, Chairman
P. Bradford
V. Gilinsky
J. Ahearne
R. Kennedy

Under the direction of RO:I, IRACT management,
duties, and responsibilities were delegated to the
Regional staff.
Directed to notify, coordinate, and act as the liaison between other Federal and State agencies
responding to the accident was Dr. Robert Bores,
Radiation Specialist, Environmental and Special Projects Section, FFMS. Assisting Bores in this roleand serving as the liaison with State agencies was
Thomas29Elsasser, a Region I-assigned State Liaison
Officer.

Staff

J. Guibert, Technical Assistant to R. Kennedy
V. Harding, Legal Assistant to J. Ahearne
H. Thompson, Technical Assistant to P. Bradford
Region I, King of Prussia, Pennsylvania

March 28, 1979-On Wednesday, March 28, 1979,at 7:45 a.m., a telephone call was taken in the NRC
110 9

APP. FIGURE 111-5. Management and Organization Structure of Headquarters
IRC and NRC, End of Day, March 28, 1979

As directed by George Smith (through Hilbert W.
Crocker, Chief, Fuel Facility Projects Section),
Donald R. Neely, Radiation Specialist and Senior
H/P in RO:I, formed the RO:I Emergency Response
Team30,31
and was named the team leader by
Smith.
Assigned as radiological members to the team
were: Karl Plumlee, Radiation Specialist and thelead H/P for TMI, Charles Gallina, Investigation Specialist (with an H/P background), and Ronald Nimitz,
Radiation Specialist Intern.
Under the direction of Brunner, members wereassigned to the OIT. James C. Higgins, Reactor Inspector, was assigned to the initial OIT (throughHarry B. Kister, Chief, Nuclear Support Section #j2);
Walter F. Baunack was assigned to the second NRC
RO:I contingent deployed to the TMI site, 32 as was
Raymond H. Smith, Investigator Specialist.
In anticipation of the public response to the incident, as is common with most incidents, an officeof Public Affairs was established. Initially, Karl
Abraham, the assigned Public Affairs Officer from
RO:I, handled this function.
As the day went on, and the public's awarenessof the incident increased through the news media,
the RO:I office was flooded with calls. Compoundi ng the problem was the fact that little information
was available in RO:I to accurately assess the situation at TMI. Eventually, more people were called in
to assist with the Public Affairs function. One of thepeople responding was James Joyner, Chief, Nuclear Materials Control Support Section.
The administrative staff provided active support
from the very beginning. Telephone communications were established, tape recorders were installed, and communicators manned the phones as
the staff obtained key data relayed from the site.
Serving the functions of communicator were
Donald L. Caphton, Chief, Nuclear Support Section,
and Richard R. Keimig, Chief, Reactor Projects Section (who left for TMI later in the day). Both of thesewere with the RO:I Reactor Operations and Nuclear
Support Branch (RONS). Also serving in this capacity were Nuclear Reactor Inspectors with the
RONS Branch William J. Raymond, who also went
to TMI later day, and L. H. Bettenhausen and Donald
R. Haverkamp (who was also Project Inspector (P/I)
for TMI). Joining them from the Fuel Facilities andMaterials Safety Branch (FFMS) were John R. Whiteand Lee H. Thonus, both Radiation Specialists.
Supporting the RO:I IRACT in assessing the radiological aspects were Hilbert W. Crocker, Chief,
Fuel Facilities and Projects Section, and Gregory P.
Yuhas, Radiation Specialist, FFMS.

Supporting the RO:I IRACT in assessing theoperational aspects was Ebe C. McCabe, Chief,
Reactor Projects Section, RONS.
App. Figure 111-6 shows the NRC's organization at
Region I and in place throughout the day. Following
i s a schedule of RO:I personnel that reflects theirrelationship with the Emergency Response Team.
Personnel Deployment
3/28/79 RO.1IRC

RO.1 Top Management

B. Grier
J. Allan

RO.1 TRACT Management

G. Smith
E. BrunnerState and Federal Liaison

R. Bores
J. Joyner
T. Elsasser

Administrative Support(Administrative staff)

Communicators and Records

D. Caphton
R. Keimig
W. RaymondL. Bettenhausen
D. Haverkamp
J. WhiteL. Thonus

Operations Assessment Staff

E. McCabe

Radiological Assessment Staff

H. Crocker
On SiteMarch 29, 1979-As Thursday morning passed, the
NRC presence on site grew and became more organized and better defined.

APP. FIGURE 111-6. Management and Organization Structure, RO:I Incideni
Response Center on March 28, 1979
By noon a group of Fuel Facility and Materials
Safety (FFMS) inspectors dispatched from RO:I arrived on site. Members of this contingent included
F. Costello, T. Jackson, J. Serabian, and B. O'Neill(all FFMS inspectors).
From Headquarters, a licensing and "clean-up" 33crew was dispatched and arrived on site; it wascalled the "Vollmer team," after its leader, Richard
Vollmer, an operations-oriented member from the
HQ Office of Nuclear Reactor Regulation (NRR).
Vollmer, prior to his departure, was designated by
the NRC management as the person in charge of
NRC forces on site.
Another member of the Vollmer team was G.
Klingler, also operations oriented, from the HQ Office of Inspection and Enforcement (IE). Klingler
was sent by N. Moseley, Director of HQ IRACT of
the HO IRC. His purpose as defined by the HO
IRACT Director was to work with Vollmer as ani nterface-liaison between the NRR Vollmer management and the RO:I management already in place andon site. 34,38
Other members with the Vollmer team arriving onsite were: G. Mazetis, Plant Procedures/ Systems

Operation; C. Berlinger, Plant Procedures/Systems
Operation; M. Chiramal, Plant Procedures/Systems
Operation; F. Ashe, Plant Procedures/Systems
Operation; H. Schierling, Plant Procedures/ Systems
Operation; and E. Adensam, Effluents, Waste, and
H/P.
From RO:III, R. Strasma of Public Affairs (PA) wason site.
By mid-Thursday, the NRC structure andmanagement organization on site was formally arranged and was becoming highly organized and welldefined. No longer did the NRC onsite team only include NRC inspectors from RO:I; nor did it comeunder RO:I's control. It was no longer consideredan OFT, but now was an NRC team.
In RO:I plans were underway for (and NRC was
preparing to institute) an NRC-manned multishiftsystem of surveillance and monitoring of TMI activities.
By shortly after noon, three more operationsoriented inspectors, one being the Project Inspector(P/I) for TMI, arrived on site. Included in this groupwere: Donald Haverkamp, P/I TMI and Operations
Reactor Inspector; D. Beckman, Operations Reac-

1112

for Inspector; and J. Johnson, Operations Reactor
I nspector.
By early evening a third NRC management
member from RO:I, E. McCabe, Section Chief,
Operations Reactor Projects Section, RONS, wason site.
By the end of Thursday, the NRC presence hadgrown from 11 RO:I to 28 NRC people, of which Region I IE accounted for 19: 3 management (2 operations and 1 H/P); 2 investigators; and 14 inspectors(5 FFMS, 3 H/P, and 6 operations). A mobile laboratory was in operation.
HQ NRC had eight people on site: one management; one coordinator/liaison, five plant systems
and procedures oriented, and one effluents, waste,and H/P oriented. All had operations backgrounds.
One person from RO:III on site was a member of
the Public Affairs group.
App. Figures 111-7 and 111-8 and the following personnel schedule reflect the NRC organization onsite, the deployment of NRC personnel throughout
the site, and their relationship to the NRC onsite
team.
Personnel Deployment
End 3/29/79 On Site
U1ECS

D. Neely
C. Gallina, Investigator
F. Costello, FFMS
J. Serabian
B. O'Neill
U2
J. Higgins, Operations Reactor Inspector
W. Baunack, Operations Reactor Inspector
W. Raymond, Operations Reactor Inspector
D. Haverkamp, Operations Reactor Inspector
D. Beckman, Operations Reactor Inspector
J. Johnson, Operations Reactor Inspector
R. Smith, Investigator
K. Plumlee

Observation Center

R. Vollmer, Management
R. Keimig, Management
E. McCabe, Management
J. Stohr, Management
J. Klingler, Coordinator/Liaison
J. Mazetis, Plant Operations/Systems
C. Berlinger
M. Chiramal

F. AsheH. Schierling
E. Adensam
J. Strasma

Off Site

J. Kottan, Mobile Lab
R. Nimitz, H/P
T. Jackson
Harrisburg, PA
K. Abraham

I ncident Response Center, IE HQ Bethesda,
MarylandMarch 29, 1979-From the NRC's perspective, thesituation at TMI had improved by late Wednesday.
Throughout the night and the next morning, NRC
prepared to change its mode of operation, and plans
were developed to go from an emergency responsemode to an accident clean-up, analysis, andrecovery mode.
By Thursday the NRC organization at Headquarters had evolved. The technical staff at the HQ IRC
and allied offices was in place, the administrative
staffs were functioning, and the management structure was well defined.
A system of shift rotation, personnel deployment,
and tours of duty, had been developed as the needarose.
As the need to monitor the situation continued
and grew, the personnel rotation system was given
more attention and became formally structured.
Personnel involved with the HQ IRC on the previous day were available on Thursday for shift duty.
To augment this group, other human resourceswere needed and were called for.
To support the EMT, from the Office of International Programs came Joseph D. Lafleur, Jr., Deputy
Director for International Programs and the Assistant Director for International Cooperation, to assist
with the liaison team.
From the Office of IE came E. Blackwood, an Inspection Specialist with the Performance Appraisal
Team (PAT) to assist as a communicator.
From the Division of Site Safety, Office of Nuclear
Reactor Regulation (NRR), came a staff of people torender assistance in the analysis, evaluation, andtechnical support functions. Included were: W.
Minners, Technical Assistant to the Director; R.
Tedesco, Assistant Director for Reactor Safety; V.
Benaroya, Chief, Auxiliary Systems Branch; L. E.

1113

APP. FIGURE 111-7. Onsite Management and Organization Structure, End of Day,
March 29, 1979 (as Perceived by Grier and Gallina)(Refs. 35 and 36)

APP. FIGURE 111-8. Onsite Management and Organization Structure, End of Day,
March 29, 1979 (as Perceived by HQ NRC Top Management)( Refs. 39 and 40)
Philips, Section Leader, Reactor Analysis Section,
Analysis Branch; G. N. Lauben, Nuclear Engineer,
Reactor Systems Branch; and S. F. Newberry,
Reactor Engineer, Reactor Systems Branch.
To assist the IRACT Plant Systems Effects
Group, C. DeBevec, Senior Reactor Inspection Specialist with the Office of IE responded.
For radiological and environmental effects cameassistance from the Offices of NRR and Research.
Representing NRR, from the Division of Site Safety
and Environmental Analysis, was F. Congel, Section
Leader, Radiological Impact Section, Radiological
Assessment Branch, and from the Division of

Operating Reactors,
Environmental Evaluation
Branch, came R. Lo, Nuclear Engineer.
From the Office of Nuclear Regulatory Research,
Division of Safeguards, Fuel Cycle and Environmental Research, came P. Reed, Chief of the Environmental Effects Research Branch.
By Thursday, there was no substantial change tothe organizational structure; therefore, the structure
established on Wednesday remained in effectthroughout Thursday (see App. Figure 111-5). The
schedule of personnel reflecting the NRC people
who responded on Thursday, as incorporated with
the Wednesday response contingent, follows.
1115Personnel Deployment

Deliso, C.
Jackson, K.
Eisenhut, D.

End March 29, 1979 HO IRC
EMTHarold Denton
Ed CaseLee Gossick
John Davis

IRACT: Communications

Whiff, K. W., Chief, Performance Appraisal, IE
Riesland, J. I., IE
Wilber, H. A., Senior Reactor Inspection Specialist,
IE
Stone, J., IE
Klingler, G., IE
Blackwood, E., IE Inspection Specialist Performance
Appraisal
Gagliardo, J., IE RO:IV

IRACT

IE Moseley, N. C., DROI
IE Thornburg, H. D., DRCIIE Howard, E. M., DSI
IE Sniezek, J. H., DFFMSINRR Stello, V., DOR
IE Bryan, S. E.
IE Jordan, E. L., DDROIIE Higginbotham, L., DFFMSI
IE Woodruff, R. W.
IE Thompson, D.

Analysis-Technical Support

Throm, E., DSS, NRR
Murley, T. E., RSR, RES
Watt, J. J., Senior Reactor Engineer, DSS, NRR
Denise, R. P., DSE, NRR
Jackson, R. E., DSE, NRR
Sobel, P. A., DSE, NRR
Marsh, T., Nuclear Engineer, NRR
Oxfurth, A., Nuclear Engineer, Instructor, IE
Shemanski, P., Senior Engineering Systems Analyst,
NRR, DOR
Mendonca, M. M., NRR, DOR
Benaroya, V., DSS, NRR
Minners, W., NRR, DSS
Orr, F., DSS, NRR
Lauben, G., DSS, NRR
Newberry, S., DSS, NRR
Tedesco, R., DSS, NRR
Philips, L., DSS, NRR
Wenzinger, E. C., NRR, DOR

EMT-Indemnity Advisory

Saltzman, J., AIG
Dinitz, I., AIG

EMT-Public Affairs

Fouchard, J. J., PA
I ngram, F., PA
Abraham, K., RO:I
Jaske, R. T., SP
Ryan, R. G., SP
Senseney, R. S., IP
RO. V

Hanchett, J. G.
Fish, R.

TRACT Plant Systems Effects Group

Beltracchi, L., DSS, NRR
Silver, H., DPM, NRR
DeBevec, C., SRI, DRO, IE
Kirkpatrick, D., Nuclear Engineer, IE
Showe, S., Nuclear Engineer, IE
Harmon, P., Nuclear Engineer, IE
Bemis, P., Nuclear Engineer, IE
Davis, D., Chief, Systems Evaluation Program
Branch, NRR, DOR

EMT-Liaison

Lafleur, J. D., Jr., IP
DeFayefte, B., SP
Gaut, H., SP
Davis, D. K., NRR
TRACT.- Operations Support Staff

Weiss, B. H.
Paulus, R. C.
Barber, G.
Hegner, J.
Ward, W.
Morales, S.
Brockett, T.

TRACT. Radiological and Environmental Effects
Group

Martin, J. A., Reactor Safety Engineer, DSE, NRR
Soffer, L., Section Leader, Accident Analysis
Branch, DSE, NRR
1116

Congel, F., DSE, RAB, NRR
Barrett, L, DOR, EEB, NRR
Bland, J., DOR, EEB, NRR
Knighton, G., Chief, EEB, DRO, NRR
Lo, R., EEB, DOR, NRR
Block, S., EEB, DOR, NRR
Grimes, B., AD E&P, NRR, DOR
Cunningham, L., Senior H/P, IE
Cohen, L., H/P, IE
Reed, R., EERB, DS, FCER, RES
On SiteMarch 30,1979-Early Friday, Region I and HQ in-

dependently decided a greater NRC management
presence was needed on site. 40
I n RO:I, plans and arrangements were underway
to send RO:I top management to the site. By late in
the afternoon, a helicopter transported the RO:I
Director, Boyce Grier, and the RO:I FFMS Branch
Chief and IRACT Director, G. Smith, to the site.
By this time, two more RO:I inspectors had arrived at TMI. They were G. Yuhas and J. White,both with the FFMS Branch, RO:I.
Meanwhile, back at HQ, management was
preparing to deploy and establish an onsite ad hoc
Executive Management Team (EMT) and NRC-TMI
field office. Accordingly, plans were being made,calls were sent out, and preparation was under way
to shuttle personnel resources from other NRC Regional Offices to the TMI site.
By afternoon, after Harold Denton was designated as the President's representative on site, a teamunder the direction of Denton, Director of the Officeof Nuclear Reactor Regulation and member of the
Executive Management Team (EMT), later called the"onsite team," or OT, flew to the site.
A great many people accompanied Denton to thesite. To serve in management capacities: V. Stello,
Director, Division of Operating Reactors and originally a member of HQ IRACT; D. Ross, Deputy
Director, Division of Project Management; B.
Grimes, Assistant Director for Engineering and Projects, Division of Operating Reactors; and D.
Mossburg, Secretary to Denton. All of these werefrom the Office of Nuclear Reactor Regulation, NRC
HQ.
To supplement the effluents, waste, and H/Pgroup already established by the Vollmer team onsite: John Collins, Chief, Effluent Treatment Systems Branch, Division of Site Safety and Environmental Analysis; W. Kreger, Chief Radiological Assessment Branch, Division of Site Safety and Environmental Analysis; T. Murphy, Division of Site
Safety and Environmental Analysis; M. Bell, Division1117

of Waste Management; V. Benaroya, Chief, Auxiliary
Systems Branch, Division of Systems Safety; and J.
Donohew, Environmental Evaluation Branch, Divisionof Operating Reactors.
To supplement the plant procedures and systems
group on site: J. Holman, Operator Licensing
Branch, Division of Project Management; and B.
Boger, Operator Licensing Branch, Division of Project Management, both of NRR. For reactor systems: T. Novak, Chief, Reactor Systems Branch,
Division of Systems Safety, NRR; and A. C. Thadani,
Division of Systems Safety.
Other members of Denton's team accompanying
him to the site were J. Fouchard, Public Affairs, and
G. N. Lawson, Analysis Branch, Division of Site
Safety, NRR.
By early evening personnel from NRC Regions
were on their way and arriving on site. From Region
II in Atlanta, Ga., came inspectors and section
managers. Included were members from the Reactor Operations and Nuclear Support Branch: Reactor Inspectors Richard Wessman, Darrell Hinckley,
Ed Verdery, Francis Jape, and John Dyer. From theFuel Facilities and Materials Safety Branch came Albert Gibson, Radiation Support Section Manager;
and Radiation Specialists Herbert Young, Dale Andrew, Gerald Thorpe, George Jenkins, Jr., Roger
Zavadoski, Larry Jackson, Daniel Montgomery, andDonald Perrotti.
From Region III in Chicago, Ill., came William Little,
Reactor Operations Section Manager; and William
Fisher and Thomas Essig, both Section Managers
with the Fuel Facility and Materials Safety Branch.
With them came Radiation Specialists Robert
Greger, Jerry Hiatt, Ronald Paul, Bruce Dicey, Thomas Tongue, William Grant, and William Axelson.
For administrative support from HO, Division of
Facilities and Operations Support came B. A. Love.
By the end of Friday, March 30, 1979, NRC had
74 people onsite: 26 from Headquarters, 23 from
Region I,14 from Region II, and 11 from Region III.
App. Figure 111-9 shows the NRC organization onsite Friday, March 30,1979. Following is a scheduleof personnel reflecting the NRC members on site intheir respective capacities.
Personnel Deployment

End of 3/30/79 On Site

OT Management and Staff
H. Denton, Director
D. Mossburg, Secretary
J. Fouchard, P/A
R. Strasma, P/A, RO:IIIAPP. FIGURE 111-9. NRC Organization Onsite, End of Day, Friday, March 30, 1979

J. Klingler
B. Love
K. Abraham, RO:I P/A, at Harrisburg

Reactor Operation

J. Higgins, RO:lW. Baunack, RO:I
W. Raymond, RO:lD. Haverkamp, RO:I
D. Beckman, RO:lJ. Johnson, RO:l
R. Wessman, RO:II
D. Hinckley, RO:II
E. Verdery, RO:II
F. Jape, RO:ll
J. Dyer, RO:ll

Procedural Review TeamsManagement

V. Stello, DDOR, NRR
D. Ross, DDir., DPM, NRR
B. Grimes, A/D, E&P, DOR, NRR
R. Vollmer, A/D, DOR, NRR
J. Collins, ETSB, PMgt., NRR
W. Kreger, PMgt., NRR
V. Benaroya, DSS, NRR
T. Novak, DSS, NRR
M. Bell, NMSS
C. Berlinger, DOR, NRR

Radiological

D. Neely, RO:lR. Nimitz, RO:lK. Plumlee, RO:lG. Yuhas, RO:lJ. White, RO:I
F. Costello, RO:I
B. O'Neill, RO:I
J. Serabian, RO:I
J. Kottan, RO:lT. Jackson, RO:lH. Young, RO:II
G. Thorpe, RO:II
D. Andrew, RO:ll
G. Jenkins, Jr., RO:ll
R. Zavadoski, RO:II
L. Jackson, RO:ll
D. Montgomery, RO:I
D. Perrotti, RO:II
R. Greger, RO:III
J. Hiatt, RO:III
R. Paul, RO:III
B. Dicey, RO:lll
T. Tongue, RO:III
W. Grant, RO:III
W. Axelson, RO:lll

Staff

J. Holman, DPM, NRR
B. Boyer, DPM, NRR
T. Murphy, DPM, NRR
J. Donohew, DOR, NRR
E. Adensam, DOR, NRR
M. Chiramal, DOR, NRR
H. Schierling, DOR, NRR
A. Thadani, DSS, NRR
G. Lawson, DSS, NRR
J. Mazetis, DSS, NRR
F. Ashe, DSS, NRR
Surveillance TeamManagement

B. Grier, RO:I
G. Smith, RO:lR. Keimig, RO:I
E. McCabe, RO:lJ. Stohr, RO:lA. Gibson, RO:II
W. Little, RO:III
W. Fisher, RO:lll
T. Essig, RO:III

Other Staff Members
C. Gallina, RO:lR. Smith, RO:I

1119

REFERENCES AND NOTESNeely dep. at 5.
GaIIina dep. at 8-10.
3
G. Smith dep. at 6-7.
4
Gailina dep. at 7.
5
Higgins dep. at 8.
6
G. Smith dep. at 5.
7
Neely dep. at 6.
8
Higgins dep. at 15.
9Kunder dep. at 94.
10
Neely dep. at 8.
1
f Gallina dep. at
12.
12
Higgins dep. at 15.
13
Gallina dep. at 8.
14
Region I IRC Tape Transcript 2, at 21.
15
Baunack dep. at 6-8.
t*Ray Smith telephone conversation on November 19,
1979.
17
Region I IRC Tape Transcript 12, pp. 15 and 22.

G. Smith dep. at 8.
GaIBna dep. at 7.
23
Stohr dep. at 22-24.
24
Grier dep. at 8.
25
Stohr dep. at 22.
2B
Keimig dep. at 13.
27
Keimig interview (IE), May 7,1979, at 1228
Stohr dep. at 22.
29Bores telephone conversation on November 8,1979.
21

1

22

2

1

BSniezek dep. at 13.
Region I IRC Tape Transcript 13, pp. 8-9.

1920

Higgins dep. at

Neely dep. at 5, 33.
G. Smith dep. at 6.
32
Keimig dep. at 6-7.
33
Moseley dep. at 85-87.
34
Moseley dep. at 84-85, 88-90.
35
telephoneconversation
GeorgeKlinglerNovember 17, 1979.
36
Grier dep. at 21.
37
GaIlina dep. at 46-47.
38
Keimig interview (IE), May 7,1979, at 12.
30
31

39

8.

40

1120

Keimig dep. at 20.
Smith dep. at 55-56.

onAPPENDIX 111.3
NRC COMMUNICATIONS EARLY IN
THE TMI EMERGENCY RESPONSE

I ntroduction

room and the NRC Headquarters and Regional
operations centers 13 hours after the accident began.

This independent appendix defines the NRC
communications during the initial phases of the
response to the accident at TMI-2. It should be noted it is not the purpose of this section to set forth adetailed chronology of NRC communications, butrather to highlight the major events.
Included within this report is a description of theevolution of a data-flow system between the TMI
site and the NRC Incident Response Centers. It begins with a general discussion of the substance of
information received prior to establishing communications with NRC representatives in the TMI-2 control room.
Appendix 111.3 also outlines the principal communications chain, the limitations, and the many modifications made to the initial communications arrange=
ment. It shows the many bottlenecks that information had to pass through between its source and the
NRC staff evaluating such information until reliabledirect communications were finally establishedbetween NRC onsite personnel in the TMI-2 control

1. COMMUNICATIONS: LICENSEE-NRC
At 4:01 a.m. on March 28, 1979, the Station
Manager for the Three Mile Island Nuclear Powerplant (TMI) was notified by one of his onsite staff
members of the events that precipitated the TMI-2
accident.' By 4:35 a.m. the senior TMI-2 supervisors were notified and by 6:35 a.m. the balance of
the key station management staff was informed of
the accident. By 7:15 a.m., less than 10 minutes prior to the declaration of a General Emergency at thesite (which came at 7:24 a.m.), key station management staff had arrived on site and was in the plant. 2
But it was not until nearly 4 hours after the Station Manager was notified that the NRC learned of
the accident at TMI.
The first attempt to contact the NRC came at
7:04 a.m. when an answering service on contract to1121

the NRC's Region I Office received the first call fromthe site, a call made to notify Region I of the TMISite Emergency declared 8 minutes earlier at 6:56
a.m.
The answering service tried unsuccessfully a
number of times to relay the information to the Region I duty officer at his home, but at the time hewas enroute to his office. By 7:38 a.m., 34 minutesl ater, the answering service successfully paged the
duty officer by signalling his beeper; however, because he was so close, he elected to continue tothe office.
Before he arrived there however, at 7:40 a.m.,another call from the site was received by the Region I answering service. This call was made to notify the NRC that the Site Emergency had been upgraded to a General Emergency 16 minutes earlier.
Within 5 minutes, the NRC telephone operator, who
also serves as receptionist at Region I, reported forwork. She learned of the call from the service andimmediately notified Eldon Brunner, the Region I
Chief of the Reactor Operations and Nuclear Sup3
port Branch (RONS), of this information.
By 7:45 a.m., Brunner had had the call from thesite transferred to the office of George Smith, Chief,
Fuel Facilities and Materials Safety Branch (FFMS).
Smith put the call from the site on the speakerphone so that Brunner and others now in his office4
Based on the information they recould hear.
ceived, an apparently joint decision was made toactivate the Region I Incident Response Center (RO:I
IRC)4' 5 Smith departed his office to begin putting
the center into operation, but Brunner stayed behind
to receive new information and to maintain an open
channel of communications with the site.
By 8:00 a.m. the Region I IRC was open, and at
8:10 a.m. the telephone connection between
Smith's office and the site was transferred to a
speaker-phone in the operations center. The telephone connection with the site was intermittently
lost during the next 30 minutes. By 8:39 a.m., however, telephone contact with the TMI-2 ShiftandSupervisor's
offices
was reestablishedmaintained. 6-9
By about 8:50 a.m., approximately 5 hours after
the TMI-2 turbine had "tripped," 10 the Region I IRC
began to "log" data from the site on incident message forms as it was received from the plant over
the open telephone line.
The forms included such data as monitor readi ngs, primary pressure and temperature indications,High Pressure Injection (HPI) rate, and notes on efforts to understand what had happened. Region I
also began asking questions of the Met Ed personnel concerning meteorological conditions. 11

By 9:15 a.m. this telephone connection became acontinuous open telephone link between the Region
I IRC and the TMI-2 control room. On the NRC endof the line at the Region I IRC was Donald Caphton, 12 Chief of the Nuclear Support Section (RONS);
on the phone for Met
Ed in the TMI-2 control room
13-15
Engineer Senior I, Nuclear.
was Ronald Warren,
By 9:26 a.m. Donald Haverkamp, NRC Region I
Reactor Inspector and Project Inspector (P/I) for
TMI, took over the Region I IRC phone to speak
directly to George Kunder, the Met Ed TMI Technical Support Superintendent at TMI-2. They discussed the apparent causes of the accident, thecurrent plant parameters, systems status, pressurizer level, and other conditions
related to the Reactor
16-18
Coolant System (RCS).
During this conversation, Gregory Yuhas, Radiation Specialist (RO:I),
interjected questions about ra19
diological data.
This system of communications was in effect until
10:17 a.m. 20 At that time all personnel nonessential
to the plant's operation were evacuated from TMI-2
because of significant levels of airborne radiation in
the TMI-2 control room. 21,22
Kunder, who was in charge of emergency communications for Met Ed, 23
decided to set up a new
telephone station in TMI-1.
Within2410
minutes, at about 10:27 a.m., Walter
25
Marshall, 'Met Ed Nuclear Engineer III, established a communications tie between the Region I
IRC and the TMI-1 Shift Supervisor's office. By
10:45 a.m. this open channel of communications wasonce again being maintained, with Leonard Landry,26 Met Ed Health Physicist, and later David
Smith, 27 TMI-1 Operator, on the phone at TMI-1.
With telephone communications reestablished,
Haverkamp directed a series of questions to Smith
concerning TMI-2 systems status. Smith turned thetelephone over to Gregory Hitz, TMI-1 Shift Supervisor.
Hitz answered Haverkamp's questions dealing
with the system's temperature and pressure, but
had to leave the phone to get the answers for otherquestions, and at 10:55 a.m. turned the telephone
over to Neely, the NRC onsite inspection team (OMl eader, who had just arrived in the TMI-1 Shift
Supervisor's office. 28,29
2. COMMUNICATIONS: NRC OIT-NRC
OFFICESBy 10:15 a.m., within 2 % hours after the NRC

learned of the accident the initial OIT arrived on1122

site. This initial team of five NRC inspectors (Neely,
Gallina, Plumlee, Higgins, and Nimitz) arrived atThree Mile Island about the time all nonessential
personnel were being evacuated from TMI-2. Thus,
they made their way to the TMI-1 control room.
3o
When they arrived at the plant, at 10:22
a.m.,
31
Charles Gallina called the Region I IRC from an extension telephone at TMI-1 and reported their arrival
on site.
After the inspection team's
initial orientation and
32-34
briefing by TMI-1 personnel
at 10:54 a.m., teaml eader Donald Neely was summoned to the TMI-1
Shift Supervisor's office by Hitz, who at the time
was on the line with Haverkamp at the Region I office. Neely took over the telephoneand discussed
35
plant status with the Region I IRC.
Again, the communications system changed
when in order to employ NRC personnel on bothends of the line, Caphton of the Region I IRC asked
Neely to assign one of the OIT members to monitor
the phone line between the Region I IRC and theTMI-1 Shift Supervisor's office. 36
By about 10:55 am., 37 prior to departing the
TMI-1 area, James Higgins of the OIT spoke briefly
with William Raymond at Region I and indicated hehad not yet been able to obtain the information requested because
he had not yet been in the TMI-2
3 ,3
control room. e s
40
Shortly thereafter, at 11:04 a.m.,
Gallina of the
Off was in the TMI-1 Shift Supervisor's office with
Neely and functioned as the site communicator with
the Region I IRC.
Fifteen minutes later, at about 11:20 a.m., about
an hour after arriving on site and some 3Y2 hours
after the NRC learned of the accident, Neely, OIT
leader, and Higgins, OIT Operations Reactor Inspector, wearing respirators,41,42
finally made their way into
the TMI-2 control room,
while Gallina, remaining
at TMI-1, continued to serve as communicator
betweenthe TMI-1 control room and the Region I
43
I RC.
44
Shortly thereafter, at approximately 11:40 am.,
George Smith of the Region I IRC, spoke with Karl
Plumlee of the OfT, who had stayed with Gallina
Smith told Plumlee to take independent air radiation45
and direct radiation readings.
On several occasions during the course of themorning, Caphton of the Region I IRC, on behalf ofRegion I and NRC Headquarters (HQ), requested
data relating to the TMI-2 reactor operations;answers were unavailable until Higgins returned
from TMI-2. Walter Baunack of the OfT (who had
arrived at about 11:00 am. with Ray Smith), was in
the TMI-1 control room with Gallina and explained
the situation to Caphton. 46

Because of the high radioactivity in the air at
TMI-2, the lack of respirators, and the order to limit
personnel in TMI-2 to essential personnel, only Neely and Higgins had gone there to get information.
Until they returned, information available at TMI-1
was limited, coming secondhand from James Seeli nger, Met Ed U 1 Superintendent. Thus, 7 1/2 hours
after the Station Manager was notified of the transient, 3 1/2 hours after the NRC learned of the accident, and an hour after the onsite inspection teamarrived, data began to flow from the OIT over the
open telephone line to the Region I IRC. By 11:40
a.m. the flow of information over this open telephoneli ne between TMI-1 and Region I was mostly of a radiological and meteorological nature. The initial information consisted of offsite release data gatheredby Ronald Nimitz of the OIT from Met Ed offsite survey teams . 47 - 48 Due to the difficulty of obtaining information from the TMI-2 control room, radiologicalinformation was to dominate the available information until about 3:00 p.m.
49
Shortly after noon, at 12:20 p.m., the communications systems were once again modified when athree-way tie successfully linked the NRC HQ IRC
to the open telephone tie between Region I IRC 50
and the TMI-1 Shift Supervisor's office, where the
OIT communicator was located. 51
On the phone for the HQ IRC, and functioning ascommunicator, was Mike Wilber, Senior Reactor Inspection Specialist; on the phone at Region I was
Donald Caphton; and at the site Charles Gallina
continued to serve as communicator.
At a glance, the following diagram graphically
depicts this three-way communications system established at 12:20 am.

By 1:05 p.m., 1 % hours after members of the OfT
went into TMI-2, Baunack reported over the open
telephone line from TMI-1 that there was still nocontact with Higgins and Neely at TMI-2. 52 Thus,
the NRC's information on the TMI-2 reactor statuscontinued to be secondhand reports based on the
periodically updated information provided by Met
Ed's TMI-1 personnel.
Shortly after 1:00 p.m. the problem was compounded by detection of high levels of radioactivity
in the air in the TMI-1 control room, requiring the useof respirators. Again, the number of respirators waslimited and OIT members Baunack and Smith, who1123

were not able to obtain respirators, left the plant for
53,54
the Observation Center across the river.
Beforehe left, Baunack informed the Region I IRC he would
report in from a telephone at the Observation
Center when55,56
he arrived. At the same time, Nimitz
and Plumlee,
OIT members, went outside to
take radiation readings.
Staying at TMI-1, Gallina began to use a respirator. 57 Because of the nature of a full-face respirator,
however, it was difficult for Gallina to communicate
and difficult for the IRCs to understand his reports.
I n an attempt to improve the communications situation, Gallina put the conference call on a
speaker-phone 58 in the TMI-1 Shift Supervisor's office.
59
At 1:55 p.m. Gallina was still using a respirator.
Soon afterward, onsite and offsite data were received60 at TMI-1 and then communicated by Gallina
to the IRCs at Region I and HQ.
By 2:45 p.m., 61 from a separate telephone line,
the Region I IRC successfully contacted the TMI-2
63
control room 62 I nitially, Met Ed's Sandy Lawyer
manned the telephone in TMI-2. Once this second
telephone link was established between Region I
and TMI-2, Higgins of the OFT, who was in the TMI2 control room, was able to address the NRC'squestions directly. However, contact with TMI-2 using this system was lost several times when Higgins
left the phone to go into the plant to get new information, and the unwatched telephone was inadvertently hung up.
With this line between Region I and TMI-2, theoverall system of communicating information to the
NRC was once again modified. Now, two separatelines from two separate locations at the plant fed
data to one location at the Region I IRC over two
separate telephone lines.
As operations-related data flowed into Region I
from Higgins, Caphton at Region I passed it on to
George Klingler, who was at the time an HQ IRC
communicator. Caphton also relayed HQ's questions to Gallina of the OFT in the TMI-1 control room.
After some uncertainty about the information being
requested by the HQ IRC, Wilber, HQ's IRC communicator who relieved Klingler, talked directly to
Gallina
Gallina, in turn,put Hitz, TMI-1 Shift Supervisor,
63,64
on the phone.
Speaking directly with HQ, Hitz
received their questions 65 and, using the hotline
66
between TMI-1 and TMI-2, spoke with Mike Ross,
TMI-2 operator in the TMI-2 control room. As Hitz
received status reports, he relayed the information
to the NRC over the three-way open line.
At approximately 3:00 p.m., Region I IRC briefly
67,66
lost contact with Gallina at TMI-1.
Shortly

thereafter, Caphton at Region I IRC reported that the
TMI-2 control
room personnel were no longer using69
respirators.
By now, HQ clearly was beginning to dominate
the three-way conversation as Wilber, HQ IRC communicator, again conversed directly with Hitz at
TMI-1. Hitz was asked: What is the means of cooling down; what is the cool-down rate; what is thepressure, vacuum; what are the parameters, level,pressure, and the feedwater flow; is there any
secondary side water activity; and what game plan
they intended to use with the power-operated relief
release on the pressurizer?
Hitz responded with some answers, but indicatedhe would have to get on the hotline to the TMI-2
70
control room to obtain more information.
At about this time, since the TMI-2 personnel
were now "off mask," Region I indicated that it
would attempt to reestablish a communications tie
with the TMI-2 control room. However, since Higgins and Neely in TMI-2 were so busy, Gallina wasrequested to have another OF
member sent to71
TMI-2 to act as communicator.
Throughout the next hour, Hitz was back on thephone periodically reporting the TMI-2 status andtrying to explain
the system's layout by referring HQ72
to blueprints.
Within the hour Gallina reported 73
that personnel in
TMI-1 were no longer using masks.
By 3:56 p.m., Norman Moseley, the HQ
IRACT-IRC Director, telephoned Boyce Grier, theRegion I Director, and informed him that the HQ IRC
was having problems getting operations informationfrom the site. Grier acknowledged his concern andi nformed Moseleythat Region I would set up a new
74,75
procedure.
By 4:05 p.m. 76 a telephone line was once again
established between the TMI-2 control room andRegion 1, 77 but there were still problems because no
one was continuously in TMI-2 serving as phone
communicator. Region I again asked Gallina to getanother NRC person into TMI-2 in order to maintaincommunications and let it be known also that Region I did not want to lose the line to TMI-1. 78 With
this attempt to reestablish and maintain contact with
TMI-2, while trying to keep contact with TMI-1, the
NRC system of communications was once again
modified.
Also by this time, NRC HQ, with Wilber acting ascommunicator, dominated the conversation over thethree-way conference line, querying Hitz about thediscrepancies in the hot-leg temperatures, 79 i nferring that the data suggested a superheated condition. Wilber questioned the validity of the temperatures reported, and discussed with Hitz the accura1124

cy of the temperature indicators in light of the rangeof temperatures. Finally, he asked Hitz a new question: "What are the incore temperatures?"
Five minutes later, at about 4:10 p.m., toward theend of the conversation, Victor Stelo, the NRR
Director, Divison of Operating Reactors, briefly took
over the phone conversation with Hitz. They discussed the temperatures, the chances of superheating (which would indicate that the core was
uncovered), the possibility of steam bubbles in thecore, valve 80,81
line-ups, and the accuracy of the thermocouples.
Again, Hitz indicated he would have to check it
out and get more information.
While Hitz was away from the phone trying to obtain answers to HQ's questions, Gallina reported radiological readings. Yuhas, at Region I IRC, questioned the source of the information; Gallina
responded by indicating that Met Ed Health Physics
Supervisor Tom Mulleavy had just called them in to82
the State.
Hitz returned to the telephone and, speaking with
Wilber at HQ IRC, stated he could not report the incore temperatures because
8s.84 of a problem with thecomputer or its printer,but he did report the
hot-leg temperatures and indicated that Met Ed felt
there was boiling in both hot legs. However, theTMI-2 people felt that there was no boiling in thecore. He then reported the pressure in the pressurizer and the fact that Met Ed was trying to cut the
bubble off. Hitz was questioned about why Met Ed
felt there was no boilingin the core. He briefly dis85
cussed their reasons.
At about this time (4:10 p.m.),88 Caphton was relieved by R. Keimig as the Region I communicator, 87
and Samuel88
Bryan relieved Wilber as the communicator at HQ.
Bryan told Keimig that the HO IRC felt it89was apparent that there was boiling in the hot leg.
Hitz came on the line and, when asked by Bryan
about the incores, responded that he had not yet
checked on them. Bryan then asked him if Met Ed
had thought of "simultaneous injection in the hot andcold legs," or if they had considered blowing it
down. Bryan informed Hitz he was definitely not telli ng him to do it, just asking that they consider it.
Hitz informed Bryan that he would once again
talk to90
the TMI-2 control room about blowing down.
After the conversation, Gallina reported that personnel in TMI-1 had put their masks back on. 91
At approximately 4:30 p.m., Bryan informed theRegion I IRC and the OIT communicator, who werei n the TMI-1 Shift Supervisor's office, that on a
separate telephone the HO IRC had TMI-2 on theline and was about to establish a three-way con-nection between the Region I IRC, HQ IRC, and theTMI-2 Shift Supervisor's office. Keimig was instructed to hang up so thatthe three-way connec92
tion could be completed.
By 4:34 p.m. 93 the three-way telephone connection was established between the TMI-2 control
room, Region I IRC, and HQ IRC. 94
The establishment of this system resulted in yet
another change to the NRC comrrurnications system. Finally, after some 6 to 7 hours with a numberof only intermittently successful attempts, directcommunication were once again established andmaintained between the NRC and the TMI-2 control
room.
When completed, there was a three-way tie
between Higgins in the TMI-2 control room, Keimig
at Region I IRC, and Wilbur at the HQ IRC.
The following diagram demonstrates the telephone connection changes that took place and thepeople manning the phones as communicators andtheir locations.

Shortly after
the switch, Higgins reported the95
TMI-2 status.
He then spoke directly with Moseley, the Director of Reactor Operations Inspection
who was serving as HQ IRC IRACT Director, and relayed key operational data and exchanged several
i deas as to the current mode of operation in TMI-2
and the actions being taken to control the reactor.
Higgins indicated he was returning to the TMI-2
control room to get an update on the plant, 98 andthat Baunack and Smith PIT members) had just arrived
and were in the TMI-2 Shift Supervisor's Of97,98
fice.
By 5:05 p.m. Ray Smith was manning the telephone in the
TMI-2 control room, serving as com99
municator.
Shortly thereafter, Kermit
Whiff became the com100
municator for the HO IRC.
By 5:32 p.m., Smith, TMI-2 OIT communicator,
suggested that the TMI-1 control room be thesource for health physics related questions because
Gallina was still there maintaining an open line to
Region I and because TMI-1 was the focal point101
forall incoming radiological and meteorological data.
1125

Following this suggestion, and in order to resolve
conflicts between the priority given operations data
versus radiological data, 102 ' 103 it was arranged that
all operations-related data would flow from TMI-2
and all health physics data would flow from TMI-1.
With this change in the communications system,
radiological data flowed to the Region I IRC, wasanalyzed, and then relayed to the HQ IRC over a
separate telephone line as depicted in the chart
below:

1126

The operations data remained as shown in theabove sketch of "After the Switch" communications.
These two channels functioned for the balance ofthe day until more extensive communications camei nto existence over the subsequent 3 to 4 days.
I n addition, on Thursday night, March 29, 1979,and during the day on Friday, March 30, 1979, a
telephone installed Thursday in the NRC Mobile Lab
on site was also used for periodic communication ofenvironmental
data to the Region I IRC and to HQ
104,105
I RC.

REFERENCES AND NOTES'U.S. Nuclear Regulatory Commission, "Investigation
i nto the March 28, 1979 Three Mile Island Accident by
Office of Inspection and Enforcement," Investigative
Report No. 50-320/79-10 (NUREG-0600), August 1979,
p. 1-3-1.
2
1d. at 1-3-15.
3
1d. at 1-3-39, 40.
4George Smith dep. at 10-11.
5
U.S. Nuclear Regulatory Commission, "Investigation
into the March 28, 1979 Three Mile Island Accident by
Office of Inspection and Enforcement," Investigative
Report No. 50-320/79-10 (NUREG-0600), August 1979,
p. 1-3-39.
eKunder dep. at 92-93.
7
Keimig Interview (IE), May 7,1979, at 2.
8
G. Smith dep. at 11.
9
Kunder dep. at 94-97.
10
U.S. Nuclear Regulatory Commission, "Investigation
i nto the March 28, 1979 Three Mile Island Accident by
Office of Inspection and Enforcement," Investigative
Report No. 50-320/79-10, Summary of Operational
Aspects (NUREG-0600), August 1979, p. 14.
"Region I Incident Message Form C1, C2.
12
Region I Incident Response Center Transcript 1 at 1.
13 Region I Incident Message Form C3.
14
Region I Incident Response Center Transcript 1 at 4.
15
Warren and Bensel Interview (IE), May 7, 1979, at 1.

Region I Incident Message Form C4-C5.
17 Region I Incident Response Center Transcript 1 at
5-10,16-18.
18
Kunder dep. at 93-96.
19
Region I Incident Response Center Transcript 1 at
11-15.
20
Region I Incident Message Form C5.
21 Region I Incident Response Center Transcript 1 at 18.
*

22

Kunder dep. at 94.
Region I Incident Response Center Transcript 2 at 7.
24
Region I Incident Message Form C5.
25
Region I Incident Response Center Transcript 2 at 8.
2326j. at 14-15.

27!. at 15-16.

28h. at 16-20.
29

Gallina dep. at 88.
Region I Incident Message Form C5.
31
Neely dep. at 12.
32
Gallina dep. at 12.
33
Neely dep. at 6.
34
Higgins dep. at 15.
35
Region I Incident Response Center Transcript 2 at
17-20.
360. at 20.
37 Region I Incident Message Form C6.
38
Higgins dep. at 16.
39
Region I Incident Response Center Transcript 2 at
24-25.
40
Region I Incident Message Form C6.
30

41

Higgins dep. at 15-16.
Neely dep. at 7.
43
Gallina dep. at 5, 7, and 12.
"Region I Incident Message Form C10.
45Region I Incident Response Center Transcript 4 at
3-5.
46
1d. at 7-13.
47
Region I Incident Response Center Transcript 3 at
12-21, 4 at 1-2.
48
Region I Incident Message Forms C6, C7, and C9.
49
Region I Incident Message Form C11.
50
GaIIina dep. at 19.
51
Region I Incident Response Center Transcript 5 at 1.
42

52k,

at 1-2.
53 Region I Incident Message Form C12.
54
Baunack dep. at 6.
55
Region I Incident Response Center Transcript 6 at 2.
58
Region I Incident Message Form C13.
57
Region I Incident Response Center Transcript 5 at 11.
58
Region I Incident Response Center Transcript 8 at 8.
59
Region I Incident Response Center Transcript 7 at 1.
14. at 4.
°'Region I Incident Message Form C16.
80
62

Higgins dep. at 18-19.
Region I Incident Response Center Transcript 8 at 9.
"Region I Incident Message Form C18.
65
Region I Incident Response Center Transcript 8 at
9-15.
66
1d. at 15 and Region I Incident Response CenterTranscript 9 at 3.
67
Region I Incident Message Form C18.
68
Region I Incident Response Center Transcript 9 at
5-6, 9, and 20.
89
1d. at 6.
701d. at 9-25 and Region I Incident Response CenterTranscript 10 at 1-7.
71
Region I Incident Response Center Transcript 9 at
6-7.
72
Region I Incident Response Center Transcript 10 at
22-25.
73
1d. at 8.
6374

HQ IRC Day 1 Transcript 01-126-CH4/22-HF-1 and
2, and 01-127-CH4/22-HF-1.
75
76

at 10.

Grier dep. at 7-8.
Region I Incident Response Center Transcript 10771d. at 12.

781d. at 15-19.

79 Region I Incident Response Center Transcript 11 at 1.

1d. at 2-4.
HQ IRC Day 1 Transcript Book 2, 01-033-CH2/20MEM-6, 7.
82
Region I Incident Response Center Transcript 11 at
4-5.
83
GaIIina dep. at 19.
80
81

112 7

84

85

6-8.

Region I Incident Message Form C20.

Id. at 14-22.
22.
98
Ray Smith telephone conversation on 11/19/79.
"Region I Incident Response Center Transcript 12
at 22.
100
Id. at 21.
101
Region I Incident Response Center Transcript 13 at
8-9.
102
Sniezek dep. at 13.
103
Grier dep. at 7.
104
Stohr dep. at 12, 13, 20-31.
10
JGrier dep. at 18.
96

Region I Incident Response Center Transcript 11 at

97Id. at

B Region I Incident Message Form C20.
R

87

Region I Incident Response Center Transcript 11 at 6.
Id. at 10.
89/d. at 11.
90
Id. at 11-14.
9t
Region I Incident Response Center Transcript 12
at 3.
92Id. at 3-4.
93Region I Incident Message Form C20.
94
HQ IRC Day 1 Transcript 01-082-CH3/21-Pd 2, 3.
"Region I Incident Response Center Transcript 12
at 4.
88

1128

APPENDIX 111.4
CHRONOLOGY OF TMI-2 HYDROGEN
BUBBLE CONCERNS

Mr. Stanley M. Gorinson
Chief Counsel
President's Commission on the
Accident at Three Mile Island
2100 M Street N.W.
Washington, D.C. 20037
Dear Mr. Gorinson:
By letter dated August 30,1979, you required that a chronology on the hydrogen
bubble flammability concern at TMI-2 be provided to the President's Commission
by Friday, September 7. It is provided here as Enclosure 1.
An explanation of the development of the chronology should aid in its
interpretation. A first draft was compiled on August 20, 1979. On August 21, thefirst draft was distributed for review by the principal staff involved with the bubble
and by the Commissioners of the NRC. Some of the staff participants provided
written responses (see Enclosure 2) and some attended a meeting on August 28
to discuss the draft chronology. As a result of the comments received, a numberof additions were made. A final draft was prepared and sent to the NRC

1129

Commissioners on August 29 and to a wider segment of the NRC staff on August
30 for review and comment. Substantial additions were again suggested. The
memoranda containing these suggested additions are provided here in Enclosure
3. Enclosure 4 is a list of the names and office affiliations of all NRC employees
who were afforded an opportunity to comment upon the final draft chronology.
Copies of the two draft chronologies and my transmittal memoranda are available
in the NRC files for your review, upon request.
Each entry in the chronology is annotated to show the source of the information it
contains. The types of sources include transcripts of Commission meetings,
transcripts of telephone voice recordings from the NRC Incident Response Center(I RC), contemporaneous notes written by the NRC staff or Commissioners, andmemoranda written since the accident. All of these source documents have been
made available to the President's Commission. For the sake of brevity, thecontents of the transcripts, notes, and memoranda have been summarized inconstructing the chronology to highlight the hydrogen flammability concerns.
I n addition to such documented entries, the chronology contains a number of"recollections." The only back up sources for the recollections are the minds ofthe individuals to whom they are attributed. The recollections were given to me inhandwritten notes or in conversations to fill in important blanks in the chronology.
I made only a limited personal review of the transcripts of the IRC voice recordingsi n constructing and editing this chronology. That review was used to corroborate
some of the significant milestones.
Where differences in substance were identified between the notes, memoranda orrecommendations of two contributors, I called the differences to their attention but
did not intervene to require their resolution. It is likely that remaining differences
are caused by irreconcilable differences in memory or by the confusion in the IRC
from March 29 through April 1 that was generated by poor communications andpoor crisis management.
With these caveats, I believe the chronology provided in Enclosure 1 identifies theorigins of the concern of the agency with the potential flammable nature of thehydrogen in the reactor coolant system at TMI-2, the sources and nature of theexpert advice sought by the agency in dealing with this concern, and the key
decisions reached on March 31 and April 1 by the Commission and its principal
staff.
Sincerely,
Roger J. Mattson, Director
Lessons Learned Task Force

113 0

Enclosures:

1. Chronology of TMI-2 Hydrogen
Bubble Concerns
2. Memoranda commenting on firstdraft of chronology
3. Memoranda commenting on final
draft of chronology
4. List of employees given an
opportunity to review andcomment on final draft.

cc: NRC Public Document RoomAll persons listed in Enclosure 4
All persons named in Chronology
Mitchell Rogovin, NRC Special Inquiry
William J. Besaw, DDC

113 1

Thursday, March 29,1979
1800-2200

Lauben (recollection)-Mattson, Novak, Minners, Is-rael, Lauben at IRC. Information from site indicatesunusual "softness" of primary system when attempts were made to depressurize. Discussed possible sources for gas bubble (zirconium-water reaction, radiolysis, steam formation). Estimated radiolysis from TMI FSAR data. Called Matt Taylor onsame subject.
About 2030

M. Taylor (memo)-l received a call at home from T.
Novak and W. Minners who were at the Bethesda
HQ-IRC. Question asked was what would be theradiolytic generation rate of hydrogen if TMI-2 reactor was to be reduced to low pressure levels to permit operation of the low pressure decay heat removal system. Taylor advised that most of his info formaking such hydrogen estimates was at Bethesda
office, but that he'd try to recall work of approximately 10 years ago and get back to HQ-IRC shortl y with an estimate.

ence of free oxygen in the vessel, I have no recollection of any information transmitted to me on thissubject. I do recall having several conversations
with B&W personnel during the evening hours ofMarch 29 and for the first few hours of March 30(before leaving for TMI-2 site) regarding a variety ofsubjects, but primarily concerned with the state ofcore coolability and the size of the gas bubble inside
the reactor coolant system. My personal recollection is that the members of the staff were evaluating
the pros and cons of maintaining the conditions thatexisted in the reactor coolant system as opposed todepressurizing the system.

About 2200

M. Taylor (memo)- I called Bethesda HQ-IRC( Minners/Novak et al.) with a back-of-envelope estimate for radiolytic hydrogen generation consideringnear-atmospheric pressure levels and non-boilingbulk coolant temperatures. These estimates madeat home relied on past experience and analysis, recall of ORNL experimental work and results, ORSORT notes of 1963, MIT handbook on Reactor
Safety (T. Thompson et al.) and extrapolations toand assumptions about TMI-2 conditions. The estimate was roughly 1.4 SCF of hydrogen per hour forthese conditions, but HQ-IRC was advised to use a
1-2 SCF of hydrogen per hour range because of
considerable uncertainty about actual TMI-2 fuelconditions and fission product releases to coolant,
etc. Taylor also advised that if HQ-IRC wanted
better estimates and more detail on radiolytic hydrogen behavior, they should make contact with Dr.
Bud Zittel of ORNL, or possibly Prof. Reed Johnson,
U. Va. (currently technical member on ASLB). Dr.
Zittel, in particular, had considerable experimental
experience with post-accident radiolysis at our (i.e.,
AEC) request approximately 10 years ago.
Evening

Novak (memo)- With regard to any information I
may have received from B&W regarding the pres1132

Friday, March 30
Morning

Mattson (recollection)-in IRC working on thermocouple data and how to get hydrogen out of reactor
coolant system so reactor could be depressurized
without interrupting core cooling.
Tedesco (notes)- considering problem of how to
get gas out without inhibiting core cooling. Calculat3
ed approximately 30 ft /day of hydrogen and oxygen at 1000 psi, 275°F from radiolysis (not assuming
recombination
andtherefore
conservative).
Tedesco estimated effect of releasing 1500 ft 3 ofhydrogen from RCS (conservative estimate ofvolume) was a 2% increase in containment concentration of hydrogen. (Based on COGAP calculation
with G=0.44 and gamma in core water of 5%).
Milstead (memo)-on Friday, March 30, 1979, Jim

Shapaker, Walt Butler and I were requested byRobert Tedesco to try to estimate the contents of abubble, then reported to be about 1000 ft 3 i nvolume, in the reactor vessel and its projected
growth rate assuming radiolysis of the reactor
coolant. We performed analyses of the postaccident generation of hydrogen and oxygen due toradiation induced dissociation of water using the
COGAP code. In addition on March 30, 1979, we
gathered all the data we could find on the limits offlammability and detonation of hydrogen-oxygen
mixtures and the overpressure effect of hydrogen
combustion.
COGAP is a computer code for calculations involvinghydrogen-oxygen concentrations within reactor containments. it is used by the Division of Systems Safety in audit
calculations performed in review of power reactor license applications. See Appendix A to Standard Review Plan Section
6.2.5.

Hendrie (recollection)- I had a series of discussions
with NRC staff at the IRC-notably Denton-on thereactor condition, the releases, etc. During one discussion with Denton on the reactor condition, which
included the estimate of a noncondensible volume inthe system of about 1000 ft3 (presumably hydrogenfrom a large metal-water reaction), I speculated on
the radiolytic decomposition rate and on whether
free oxygen was being generated and going into the
bubble. My initial thought was that the net evolution
rate of oxygen was probably small, due to therecombination (or back-reaction). I recalled that ahydrogen-gas overpressure is used in PWR's to inhibit net oxygen evolution in normal operation, andthat the effect was probably going on in the present
accident condition. However, I wanted an estimateof the net oxygen evolution rate and asked Denton
to put some people to work on it. I later repeatedthis request to other staff members. I also asked
for estimates of the flammability limit and the detonation limit (the lowest oxygen concentration, inhydrogen-steam, for upward flame propagation andfor an explosive mixture).
MiddayDenton (memo)- My recollection is that Chairman
Hendrie was the first to call my attention to the possibility of combustion of the hydrogen within thereactor vessel. Conversation took place by phone
on Friday, March 30, sometime after I had arrived at
the site. I am fairly certain it occurred after I had
been made aware of the pressure spike from hydrogen burning within the containment. I recall that I
first heard about the spike while in a car proceeding
to the helicopter.
Tedesco (notes)-calculating rate of growth of gas
volume by radiolysis using conservative estimate ofsource terms because of incomplete information of
actual TMI-2 situation.
1240

Mattson telecon with Hendrie and other Commissioners (Comm. transcripts)- Mattson summarizes
thermocouple data and their implications for staff's
earlier conclusion of extensive core damage; reports
learning earlier that morning of containment pressure spike on Wednesday afternoon and staff conclusion it was hydrogen explosion; reports methodsof measuring volume of bubble in vessel andpresent size of bubble; concludes that the bubble ismostly hydrogen; indicates that radiolytic decompo1133

sition would be very small, therefore bubble musthave been caused by considerable amount ofmetal-water reaction; reports difficulty in finding
ways to get rid of bubble without uncovering thecore; expressed concern that bubble could grow byradiolysis and eventually uncover the core.

About 1540

Hendrie telecon with Thornburgh (Comm. transcript,
pages 126 and 127)-

Phone voice: What are the potentials for an explosion that would rupture the core? Rupture thevessel?

1600

Chairman Hendrie: There isn't any oxygen in there
to combine with that hydrogen so the answer as far
as I know is pretty close to zero.

Lanning (memos)- requested by Ron Scroggins tojoin himself, Stan Fabic, and Pete Anderson to go to
Bethesda concerning accident at TMI-2.
Briefed by R. Budnitz concerning existence of
bubble in reactor vessel. Presented data of pressure versus change in pressurizer level and change
i n incore temperature measurements. Bubble size
was approximately 1000 cubic feet © 1000 psi and
280°F, and increasing. Concerned that core would
uncover due to growth. Participated in performing
heat-up and boil off calculations for core.
About 1828

Hendrie telecon with McCormick (Comm. transcript,
page 192)- Congressman McCormick apparently
asked if the hydrogen in the vessel could react.
Hendrie replied:

Chairman Hendrie: No, because we're only at a
thousand pounds. That will be one of the things
that people will be looking at, Mike. I don't know-I
don't know-well I ought to be getting an updatefrom the site at any moment now. I'm not surethat-I think the reactor situation will keep it in thisstate for another day or so probably while we try tothink through very carefully the, you know, theroute out from here. I don't think, you know, there
isn't anything in the core it can react with. You
know, ha?; No. There's either none or very little,
because the hydrogen got there from a
metal-water reaction and you don't get, it isn't a radiolytic bubble.

About 1930

Commission discussion of hydrogen in vessel(Comm. transcript, pages 217 to 225)- Hendrieanswers Bradford question on why reactor won't go
cold in its present situation:

Chairman Hendrie: The problem with this thing isthat-I'll get to Roger and his troops later tonight. I
want a calculation of the radiolytic disassociation
rate. At the moment, we've got a hydrogen bubble
with some steam-maybe some steam in it in thehead of the vessel. It's probably pretty pure hydrogen. The reason is that the evolution is from a
metal-water reaction in which you just get hydrogen, you don't get anything else in a gaseous form.
There are two other ways that you get hydrogeni n these situations, however, and the one which isof concern is the radiolytic disassociation of water,
just ionization; just ionizing the particles of water
gives you hydrogen and oxygen.
Now some of the oxygen will trap out as oxideon the structure but some of it will work its way
back up. So over some period of time which isprobably of the order of many days or a week orweeks, you're going to begin to get enough oxygen
up in there to worry about the thing.
And if there's anything I don't particularly think I
need at the moment it's flammable-you know, forthe bubble to be in a flammable configuration.

This generates a discussion about how long it
would take to reach flammable mixture (Hendriesays "a long way out ....guessing its some days"),
how much oxygen would be required (Hendrie says
"you need to get up to 4 percent by volume oxygento have a mixture which is minimally flammable"),and whether there is oxygen in the bubble (Hendriesays "there's probably no oxygen up there now, but
as time goes on, definitely why you'll keep building
oxygen ...)". Hendrie concludes this part of conversation by saying that he'll make sure a team isstarted working on radiolytic decomposition calculations.
2000

Lanning (memo)-T. Murley (INEL notes) requested
L. Ybarrondo and others at EG&G, Idaho to ascertain the detonation potential of hydrogen gas inreactor vessel (details of request unknown).
After 2000

Lanning (memo)-W. Lanning and T. Murley initiatedSemiscale Test to explore venting of bubble throughpressurizer relief valve. Obtained system volumes
and pipe sizes from Ed Kane at B&W/Lynchburg.
Obtained current TMI-2 conditions from Tad Marshat IRC. Bubble volume in TMI-2 was 1000 ft 3 . pressurizer pressure 1100 psi and hot leg temperature
280°F. Noted that pressure surge line had potential
for water seal due to geometry layout provided by
B&W. Recollect there was a lot of uncertainty concerning size of relief valve opening.

After 2200

Lanning (memo)-Reviewed system description andpiping diagrams concerning ways to vent bubble.
Reviewed make-up and purification system in attempt to resolve blockage of letdown line.
Evening

Butler (recollection) and John Weeks, BNL (memo)Walter Butler of NRC asked me to estimate
the possible build-up of hydrogen in the containment by radiolysis of water in a high field. I in turn
discussed it with Dr. Harold Schwarz of BNL Chemistry Department. His rough guess was that the hydrogen may build-up to several percent whichshould be approaching the ignition point. The higher
the temperature (above 100°C), however, the greater
would be the recombination rate and the less thebuild-up of hydrogen.
After 2240

Hendrie telecon to Eisenhut at IRC (notes and IRC
voice transcript)-Hendrie concerned over conditionof bubble; Hendrie making calculation that isn't comi ng out good; Hendrie and Eisenhut estimatedvolume of helium fill gas in fuel rods; Hendrie says
he has asked people to worry about oxygen evolution in the vessel coming from radiolysis; asks
Eisenhut to get other people to do a totally independent calculation of evolution rate; Hendrie asks for
estimate of detonation pressures; Eisenhut notes his
having talked to (Tom) Anderson of Westinghouseto get an independent estimate of radiolysis;
Eisenhut says he will also ask Levine and his people
to start working on the problem.
About 2300

M. Taylor (memo)- took phone call at site from
Chairman J. Hendrie, NRC, who asked that the foll owing item be relayed (note on this call passed to
D. Ross): Express concern about oxygen evolutioninTMI
reactor vessel
andpossibility ofhydrogen/oxygen explosion; he asked for theseconcerns to be relayed to Bethesda staff so theywould get moving on an assessment.
2400

Commission discussion (Comm. transcript, pages
227-229)-After telephone conversation with Stelloat site, Hendrie discusses radiolytic decomposition,back reaction in clean and dirty water, change in 4
percent flammability limit as a function of pressure,
etc.
1134

Lanning (memo)- monitored progress of Semiscale

Saturday, March 31

Test. Transmitted preliminary results of first test to
B&W and IRC. B&W requested second test, doubling the size of the bubble and including HPI flow.

0015

Eisenhut (notes)-told Stello at site that IRC con-cerned with hydrogen explosion-hydrogen and oxygen mixture in dome (of reactor)-notes containreference to Dr. Zittel of ORNL.

0530
Minners (notes) telecon with Jim Taylor of B&W-

explosive force of stoichiometric mixture of hydro3
gen and oxygen (1000 ft @ 1000 psi, 280°F, instantaneous burn) is 14000 psi.

Early a.m.
Hendrie telecon to Eisenhut (notes and IRC voice
transcript)- Hendrie asks is gas stripped out indome (of the reactor) or is it going around in loop?
Eisenhut says that Taylor (at site) and B&W areboth working the questions on radiolytic evolution ofoxygen (and detonation of hydrogen).

0535

Stello telecon to Eisenhut (notes)- asks for best

expected gas evolution rate; can we get burn inreactor vessel or piping?; contingency plan. D.
Eisenhut and S. Hanauer tell V. Stello of B&W
results for hydrogen burn in RCS (see 0530 above).

0100-0200

M. Taylor (memo)-called Bethesda HQ and relayed

to Dr. S. Hanauer the concern about oxygen evolution and the possibility of explosion in the reactor
vessel. Taylor asked Dr. Hanauer to assure staff
gave prompt attention to this matter.

About 0700

Lanning (memo)- At request of W. Minners and incoordination with S. Levine, B. Budnitz, T. Murley(and I) supplied information to INEL, Battelle
Columbus and Sandia Laboratories to calculate hydrogen burning and explosion potential. S. Levinetransmitted results (of the Semiscale test) to IRC.
Assisted in evaluating various methods for scavenging hydrogen from primary coolant system.

About 0200

Hendrie telecon to Mattson (recollection)- check
oxygen addition rate and potential for RCS explosion; Hendrie calculations of oxygen generation ratei ndicate there is a problem. Hendrie said he talked
to Eisenhut earlier about this problem, but wanted
Mattson to confirm that people were working on it.

Early a.m.

Budnitz (recollection)- I n conversation with Saul

0200
Minners (notes) telecon to W. Lanning in RESResearch staff getting calculation started on hydrogen explosion. Notes contain reference to Dr. Zittel
of ORNL.

0200

Lanning (memo)- Received call from W. Minners
who requested a calculation of the explosive force
of a stoichiometric mixture of hydrogen and oxygeni nside vessel. Assume mixture contents for a 1000
cubic foot bubble at 1000 psi which would produce
the largest force.

After 0200

Lanning (memo)- W. Lanning (memory) requested
L. Ybarrondo (EG&G) to perform calculation requested by Minners.

Levine and Tom Murley of RES, either late Friday or
early Saturday, the following divisions of responsibility were arrived at. All tasks were to be carriedout by contact with contractors and consultants
around the country. I was to be in charge of worki ng out at what level of oxygen in pure hydrogen thethreshold of combustibility would be reached, and at
what higher threshold the explosion possibility
would set in. I was then to be concerned with theproperties of a fast combustion event and of an explosion, such as the duration of and strength of thepressure pulse inside the TMI vessel from such an
event. I was also to be concerned with finding any
possible mechanisms that might set off such a
combustion or explosion event inside the primary
TMI vessel. Finally I was to try to find experts who
could suggest and evaluate methods (using chemicals or physical means) to remove or decrease thehydrogen within the primary system.
I recall that Tom Murley undertook the work with
Wayne Lanning to study the feasibility of hydrogen
removal out the pressurizer relief valve. This last1135

resulted in performance of a quick experiment early
Saturday morning at Semiscale at Idaho National
Engineering Lab, and another on Monday morning,
April 2.
. I recall that beginning on Saturday morning
Levine and Murley undertook to contact experts on
the issue of how much oxygen build-up there would
be in the primary system, including the crucial factorof oxygen recombination.
After 0800

Lanning (memo)-W. Lanning (memory) assisted R.

Budnitz in evaluating various methods for scavengi ng hydrogen from primary coolant system. Discussed Minners' request with S. Levine, R. Budnitz
and T. Murley.
1030

Hendrie telecon to Mattson (Comm. transcript andIRC voice transcript)-acknowledges that Eisenhut
had passed information to Commission from B&W
about hydrogen burn in reactor vessel (see 0530
above), and asked about oxygen generation rateand Westinghouse calculation; concerned about rapid approach to flammability. Hendrie asked Mattson to put pressure on getting answer.
About 1035

Commission discussion (Comm. transcript)-Hendriereports to Commissioners that Denton is working on
bubble problem.
1100

Lanning (memo) and Noonan (recollection)- V.
Noonan contacted B. Saffel (EG&G) requesting
status of finite element reactor coolant systemstress model if needed for a hydrogen detonation
calculation.
After 1100

Lanning (memo)-Transmitted preliminary results ofSemiscale test to B&W (Bob Jones). I recall S.
Levine discussing results with someone at IRC.
Discussed results of test with J. Cudlin (B&W)
and calculation performed by B&W.
a.m.

Budnitz (memo)-l worked heavily on Saturday and

Sunday on the question of understanding the issue1136

of hydrogen combustibility and kinetics in a reactor
vessel such as at TMI. On referral from Richard
Garwin of IBM, I called Dr. Harry Petschek of AVCO
Everett Research Laboratory on the morning of Saturday, March 31, finally reaching him at home in latemorning. He responded immediately by indicatingthat he and some colleagues could assist in understanding the issue of hydrogen combustibility andcombustion kinetics in a reactor vessel such as at
TMI. Later that day and through Sunday, April 1, I
spoke, two or three times, to Dr. Petschek and one
or two of his colleagues. I was their sole NRC contact as far as I know. They worked on the questionof what concentration of oxygen in pure hydrogen
would be the threshold for combustion, particularly
at the temperatures and pressures thought to bepresent at TMI (about 1000 psi at many hundreds ofdegrees F), and reported back sometime Sunday on
those. Dr. Petschek also referred me to Dr. Bernard Lewis in Pittsburgh, who turned out to be ahighly-regarded expert in just these same issues. I
finally reached Dr. Lewis on Sunday morning, April 1(see below).
Twice during this period (Saturday, March 31) I
talked with Dick Garwin about hydrogen combustion. He gave me insights into how important theback reaction is in a proper calculation of the pressure pulse during a fast burn or detonation of hydrogen in a vessel like the TMI reactor vessel.
Budnitz (memo)-All day Saturday I worked, off andon, on the idea that a snake-like device might beobtained which might be inserted into the primarysystem to remove the "gas bubble." Dr. Richard A.
Garwin of IBM first suggested this idea to me. I
telephoned Dr. Heinz Heinemann of Lawrence
Berkeley Laboratory on this subject, and on his referral to Mr. Joseph Penick of Mobile Oil. Later thatday, Saul Levine contacted Edward Mason of Amoco on the same subject. Although much effort wasspent on the part of many people in those companies, and there were many telephone calls backand forth between NRC (me) and various people,
neither contact ultimately resulted in anything of use
to us.
I contacted Mr. Penick on Saturday morning,
March 31. He said that he thought Mobil could assist NRC with advice on the availability of snake-likedevices to extract gas from a TMI-like pressure
vessel. He called back later during the weekend (Irecall his return contact as occurring on Sunday,
April 1) and indicated that devices such as wesought were not readily available in the Mobil Corporation, and unlikely to be available elsewhere in
the petroleum industry. The problem was that thepath into the reactor vessel from the outside to theupper dome was too tortuous for the use of thedevices that did exist, and the fabrication of a special device would be quite difficult. I believe that I
was Mobil's sole NRC contact on this subject. Our(negative) results were communicated from time toti me to the IRC people, mainly to R. Mattson and D.
Eisenhut in my recollection.

Budnitz (memo)-As a subsidiary activity on Satur-

day and part of Sunday, I attempted to find experts
around the country who might suggest various
chemical means to remove hydrogen from the primary pressure vessel. I first called Dr. Heinz
Heinemann of Lawrence Berkeley Laboratory, in themorning of Saturday. Dr. Heinemann is a chemicalengineer at my former laboratory in Berkeley and is
a colleague and friend there, who spent most of hislife working for Mobil Oil Corporation.
Dr.
Heinemann discussed with me the question of addition of catalytic chemical agents to decrease thehydrogen in water solution. Dr. Heinemann gaveme the names of several catalysis chemists who
might have expertise in this matter, and also enlisted
the advice of two Berkeley colleagues. We talked
several times over the weekend of March 31-April 1,
but I learned sometime on Sunday, April 1, that thisproblem was being attacked by engineers at the
GPU Service Corporation, and I turned over to Bob
Cutler at GPUSC the names of experts I had turned
up.

Budnitz (memo)-Dr. Laura Cherubini called me on

her own from her home in Billerica, Massachusetts,
on Saturday, March 31, with a suggestion of
biological/chemical means to reduce or eliminatehydrogen dissolved in the reactor coolant water. I
do not know how Dr. Cherubini received a reference
to me. The method was to use algae that trap hydrogen from solution by presence of free electron
acceptors. Since I was not expert in this matter, I
turned it over to others at NRC for follow-up. However, by the time anything more could be done withthis suggestion, the perception of the importance ofa "hydrogen bubble" had diminished, and I think thatno further follow-up occurred.

1050

Mattson (notes) telecon with Tedesco- Discussed

results of B&W explosion calculation (see 0530,
above). Mattson listed questions for Tedesco toask of Westinghouse (and KAPL). They were (1)evolution rate, (2) how soon flammable, (3) is oxy-

gen stripping out and going into dome, (4) is oxygenstaying dissolved, (5) what does it mean as we go
to flammability limit, and (6) how does flammability
li mit change at high pressure. Westinghouse (BillBrown) estimated that at 3 days the total gas generation by radiolysis will be 7700 scf.
a.m.

Mattson (notes)-told Tedesco to go to Brodsky to

get Naval Reactors help on hydrogen and oxygen
problem after 12 noon. Case had suggested to
Mattson that Brodsky should be asked to help on
this problem.
Levine (memo)- I spoke with Robert Ritzmann of

Science Applications concerning hydrogen and oxygen generation rates in TMI-2 vessel in the period
March 31-April 1 (starting Saturday a.m.). He informed me that although one could calculate an increase of 1% oxygen per day without considerationsof a reformation rate of hydrogen and oxygen due
to bubble back pressure, that the 1% rate was probably too high. He also said that he felt the rate wasprobably no higher than 0.1 percent per day andcould be zero, but that he did not have the data tocalculate an explicit rate.
I spoke with Dr. Kouts of BNL several times on
Saturday and Sunday concerning the possibility of ahydrogen explosion in the reactor vessel. His view
was that this would not be likely. He referred me toHarold Schwarz (on Sunday-see 1500 hours) as asource for precise information.
Noonan (memo and recollection)-The Engineering

Branch of DOR contributed in the review andevaluation of two main issues regarding the TMI-2
event: 1) Potential overpressure within the reactor
coolant system due to a postulated detonation of
the hydrogen bubble, and 2) the determination andspecificationofreactorvesselpressure-temperature limits for various postulated
cooldown transients. We did not keep a log of ouractivities, however, senior members of our staff
worked a number of evenings and several weekends as well as regular hours in late March and early April on these issues.
While we were of the opinion (Saturday afternoon) that the hydrogen could not explode due tothe sparcity or absence of oxygen (see excerpt of
memo by W. Hazelton, below), we were directed (byDarrell
Eisenhut)toassumespecifiedhydrogen/oxygen ratios and determine detonationpressures. The actual calculations were performed
for us by Dr. Norman Slagg and his staff at USA
1137

ARRADCOM, Dover, N.J., who also had the results
confirmed by Lawrence Berkeley Lab., University ofCalifornia (see Attachment 2). The results of theseanalyses are in our files. We also had several
phone discussions with B&W regarding this matter.
EB personnel evaluated the dynamic response of
the reactor vessel to the postulated hydrogen detonations.
Noonan does not recall to whom he passed hisand Hazelton's concern that Ritzman was in error
about the possibility of oxygen being generated. He
remembers talking to Research people, with whom
he was in close proximity in the Maryland National
Bank Building Offices of NRC, and he recalls talking
to NRR people by telephone who were located in IE
offices just outside the IRC, but he doesn't
remember who, specifically, he gave the message toon Saturday afternoon that he believed Ritzman was
wrong. Although Noonan felt that there would be no
net oxygen generation in the TMI-2 vessel, he knewthat others were doing more sophisticated calculations. Therefore, when asked to do the explosion
and stress calculations for the reactor coolant system, he and his people proceeded with Dr. Slagg(see below, Saturday evening) to answer what they
thought was a conservative question of "what if aflammable or detonable mixture is reached?"
Hazelton (memo)-Because I heard that there was ahydrogen bubble in the reactor vessel, I wanted toevaluate the possibility of hydrogen damage to thereactor vessel material. After coming to the office(about 9:00 a.m.) and checking information in myfiles, I concluded that there would be no problem in
the near term, but this was based on information
about 15 years old. Therefore, I decided it would be
prudent to check with experts in this field. I called
Dr. John Weeks of Brookhaven and Richard T. Begley of Westinghouse, explained the situation anddescribed the conditions. They both called backafter several hours and confirmed that my analysis
was correct. Mr. Begley reminded me that Dr.
Shewman is also particularly knowledgeable in thisarea, and suggested that I check with him, which I
did. Dr. Shewman called back after about threehours and again confirmed my assessment that the
specific alloy used in the reactor vessel( Manganese Moly)-is resistant to hydrogen damage, and that no bad effects would be expected unl ess the pressure and temperature were significantly
i ncreased for long periods of time.
I n parallel with this activity, I was helping othermembers of the Engineering Branch in the assessment of effects of a possible explosion in the reac-

for vessel. Input to us included the percentage ofhydrogen, oxygen, and steam in the bubble. I expressed concern that the oxygen level assumed
was far too high, and in fact, I believed that it would
be negligible, and no explosion should be postulated. I asked Mr. Noonan to find out why high oxygen
levels were being assumed. He found out (fromTom Murley) that a man named Ritzmann was doing
the calculations, and obtained his phone number. I
called him (about noon), we discussed the approach
he was using, and I expressed my concern that no
credit was being taken for recombination in the dissociation calculations. He referred to some oldwork done by Fletcher and Gallagher that I was notfamiliar with. I then decided to check with the man
they had reported to, Paul Cohen (ex-Westinghouse
and Bettis, retired), and John Weeks of Brookhaven.
They both confirmed that the high hydrogen overpressure would drastically inhibit the dissociation
production of oxygen, and in fact, one way to remove the hydrogen might be to add oxygen to thewater to "getter" the hydrogen. I relayed this information, including recommendations to check with P.
Cohen through Mr. Noonan to the group responsible, but apparently I did not succeed in changing
anyone's mind, because for several days I kept
hearing on television that the reactor vessel was ini mminent danger of blowing up because the oxygen
level was increasing to the danger point: I was not
pleased.

John Weeks, BNL (memo)-Warren Hazelton asked
me what information I had on the thermodynamics
and kinetics of the reaction of hydrogen at a hightemperature and pressure inside the reactor vesselon the possible decarburization of and methane formation in the vessel material. I discussed this subject with David Gurinsky and J. Chow of BNL, M.
Gensamer, Professor Emeritus at Columbia and A.
Ciuffreda of Exxon Research. The stainless steel
cladding on the inner surface of the vessel would bea partial barrier to hydrogen provided it were intact.
There is enough of a chance of a flaw in this cladding, however, that no credit should be taken for it
i n estimating the performance of the reactor vesselmaterial. The reactor vessel is made of a pressure
vessel steel (ASTM A-533-B) which contains 1%
Mn, 0.5% Ni and approximately 0.5% Mo. The oil industry is continuously concerned about hydrogen
induced decarburization of steels in their refinery
equipment. They have prepared a graph stating thesafe temperature and pressure for steels (Nelson
Diagram) in the American Petroleum Institute report
API-941, which was most recently modified in 1977.

1138

A steel of the composition used in the Three Mile Island vessel should be safe from decarburization by1000 psi of hydrogen at temperatures up to 7000°F
for indefinite use. Exceeding this temperature orpressure for short periods would not cause serious
damage as there is a definite incubation time, of amatter of several days, before problems begin todevelop. Mo appears to be even more effective
than Cr in retarding this decarburization although
the reasons are not clear. The same steel without
the Mo would only be safe up to 500°F at 1000 psi
of hydrogen. I think the upper part of the reactor
vessel should be carefully checked for any possible
damage from decarburization prior to its return toservice. A copy of the curve showing this relationship as revised in 1977 is appended to thismemorandum.
Hazleton also asked whether radiolysis of thewater within the vessel could add oxygen to the hydrogen gas bubble. In my opinion, it should not.
Radiolysis of water proceeds by a complex chain
reaction and can be prevented even by a small
overpressure of hydrogen in an operating PWR.
The high hydrogen pressures over the coolant atThree Mile Island should totally prevent oxygen formation. In fact, Harold Schwarz stated it may befeasible to remove the hydrogen by simply adding
oxygen slowly to the coolant; this could, admittedly,
be risky. I think we should be very careful not touse chemicals such as sulfate or sulfur bearing
compounds to react with the hydrogen since these
could be reduced by the excess hydrogen to sulfides which are very harmful to a number of the materials in the system, especially the Inconel steam
generator tubes. It might complicate the return of
the unit to service. I recommended that a nitrate(such as potassium nitrate) be used if one wished to
go by this route. However, I think the best means ofhydrogen removal would be through venting it fromthe primary coolant into the containment where it
can be recombined with oxygen.
1130

Gilinsky (Comm. transcript)-major hydrogen problem in the pressure vessel.
1145

Gilinsky (Comm. transcript)- people in IRC talking
about10% oxygen.

Commissioners (Comm. transcript)- discussion ofvessel rupture by hydrogen explosions in RCS generating missiles or containment rupture.

1139

1145
Hendrie (Comm. transcript)-1000 cubic feet of hydrogen in vessel, if released to containment, takes
you well into the flammability range. Wants an opinion from the flammability crowd-I've got it out
working in the vendor shops and elsewhere, Bettis
and so on.
Late a.m.

Murley (memo)- On Saturday, March 31, we received a question from the staff at the IRC whether
there could be sufficient oxygen gas in the primarysystem to form an explosive mixture and thereby
constitute a threat to the reactor pressure vessel.
The answer to this question proved to be elusive.
I discussed this question with staff members fromI NEL (Sid Cohen, Ron Ayers and Jack Liebenthal).
Concurrently, Saul Levine called Bob Ritzmann of
Science Applications, Inc., and we understood that
Bob Tedesco of NRR was contacting staff at KAPL.
The information I received from INEL was based onreported data from the Cooper plant (a BWR) andwas scaled down to the power level of 25 MWt.
Their conclusions, which they stressed were extremely conservative, were that the hydrogen bubble contained about 2.2% oxygen and that it would
take at least 4 to 5 more days to reach 5% oxygen
concentration. I was later given some data from theAdvanced Test Reactor (ATR) that was purported tosupport the data from the Cooper plant.
I found it very difficult to piece together all of thei nformation into a consistent story. The Cooper
BWR data were not directly applicable to TMI (aPWR) although there was some boiling in the TMI
core. Similarly, the ATR is a low pressure (150 psi)
reactor and was also not directly applicable to TMI.
Late on Saturday evening I received a call from Rob
Ritzmann who reported that he was not having
much luck in calculating the oxygen concentration,although he believed it was below the flammability
li mit.
About 1200

Tedesco (notes) called Brodsky- got name andnumber for Venurs at KAPL.
1200

Denton telecon briefing of Commission and IRC staff(Comm. transcript and lRC voice tape)- general
briefing on status at site by Denton. Hendrie tells

Denton that he talked to Mat (Taylor) and Vic Stellol ast night about a concern that he (Hendrie) had
about evolving oxygen from radiolytic decomposition into the bubble. At some of the rates that havebeen quoted we're either at or getting close to flammability if the 4% limit is correct at 1000 psi. We've
got people from Bettis and Westinghouse working
on it. Hendrie says this must be considered in thesense of what sort of risk it presents and what doesit mean about our judgment on advising the Governor either for some further evacuation-limited evacuation measures or a general recommendation.
We didn't cover this scenario with the Governor.
Hendrie says either he or Denton should call theGovernor and make him aware of it. Denton says
he calls the Governor every two hours and will follow up with it the next time he calls.
Two concerns are expressed: 1) are we alreadyclose enough to a situation (hydrogen + oxygen
explosion in the reactor vessel) where we ought toconsider some further evacuation and 2) if we get
the bubble out to containment, belief is expressedthat we'll be flammable.

KAPL's initial reaction that recombination in the
bubble was not a strong possibility.

1400

Tedesco telecon to Mattson (notes)- Tedesco re-ported that Westinghouse (Brown) working andNavy (E. Venurs of KAPL) working on hydrogen
evolution rate calculation. Depressurization will not
get rid of all gas because of high point collection,
describes best conditions for depressurizing.

1406

Tedesco (notes)- Westinghouse believes oxygen

may stay in solution; at low temperatures, therecombination of hydrogen and oxygen is not likely.
KAPL can't preclude free oxygen at this timeoxygen and hydrogen generated by radiolysis notli kely to recombine if there is "boil off." Release of
all hydrogen in RCS to containment yields 2 volume
percent hydrogen increase in containment.
About 1415

1310

Levine te/econ to Mattson (notes)- Levine reportsthat Ritzmann of SAI (formerly at Battelle Columbus
Laboratory and a physical chemist used by the
Reactor Safety Study for his hydrogen expertise)says 2% oxygen present now, could be 3 dependingon g-factor (the rate of production from gammas
could be 10 times higher, but Ritzman doesn't beli eve it). Ritzman also tells Levine that mixture ignition could occur at 8 to 9% oxygen, with detonation
higher by factor of 2 or 3. Levine also reports that
Sid Cohen (INEL) says 5% oxygen in 4-5 days;
900°F required for spontaneous detonation in wet
environment; burns first.

1400

Milstead (memo)-On Saturday, March 31, 1979, we

contacted GE personnel at KAPL regarding theTMI-2 program. At about 2:00 p.m. on March 31,
we first talked to the GE personnel. We asked themfor information regarding the flammability and detonation limits for oxygen/hydrogen mixtures andpressure effects and Navy data on experimental
determination of radiolysis rates. We asked that
KAPL also use their resources to try to estimate thecontents of the bubble and its possible growth rate.
The possibility of gamma induced recombination ofhydrogen and oxygen was discussed and it was
1140

preparing Hendrie for press conference. Describedcurrent state of knowledge of IRC staff. Relied on
i nput from Levine (1310 above) and Tedesco (1400
above). I do not recall telling Chairman Hendrie ofeither a plus or minus uncertainty in the preliminary
estimates of Mr. Ritzmann that had earlier been provided to me by Mr. Levine. I do recall telling the
Chairman of both the Ritzmann and the INEL estimates relayed to me by Mr. Levine.
Mattson (recollection)briefsHendrie

at !RC-

1445
present situation is not one to hold for a long time;principal problem at the moment is to work outmeans of working with gas bubble in the vessel;
may be prudent to evacuate as precautionary
measure when changing status of reactor to deal
with bubble; consider evacuation to distances
between 10 and 20 miles; considering options forremoving gas bubble; concern over potential for explosion of hydrogen in the vessel; working on thatproblem very intensively; no ignition sources at
hand; preliminary indication is that we are some timefrom any possibility of a flammable condition. Case
recalls elaboration on the risks of the various options for continued core cooling-depressurizing or
not depressurizing.
Hendrie and Case press conference (transcript)-

1500

Denton telecon to Mattson (notes)- reports that
Stello stopped degassing by Met Ed because ofconcern with hydrogen addition to containment;
Denton concerned with hydrogen in vessel; Novaksays GPU wrong, bubble size not decreasing.
1527

Full Commission meeting (transcript, p. 28)- i n IE
directors office with Case and Mattson; concentrated on potential for hydrogen explosion in Reactor
Coolant System. Mattson, relying on Ritzman input
to Levine, advises that it will require several days toreach flammability limit and he is confident that estimate is not an underestimate of the explosion potential at that time. Uncertainties in the estimates
were discussed.
1600

Milstead (memo)-At about 4:00 p.m. on March 31,
1979, we again contacted KAPL. KAPL provided us
with the results of experiments run for the Navy todetermine the flammability and detonation limits forhydrogen/oxygen mixtures in a range of pressuresand temperatures applicable to the TMI problem.
Based on their information and our estimates of hydrogen and oxygen concentrations in the bubble,
we estimated that we were near the lower flammable limit in the bubble. KAPL informed us that
combustion at the lower flammability limit would
result in a very small pressure increase (about afactor of 1.2). Based on bubble and oxygen growth
rates which we had calculated we estimated that it
would take about 10 days to 2 weeks to reach thelower detonable limit in the bubble. KAPL indicatedthat because of the low temperature in the bubble,
they would not predict recombination of hydrogenand oxygen in the bubble. KAPL indicated that
gamma induced recombination would be more likely
in the reactor coolant liquid and indicated that they
were looking into this.
1605

Tedesco (notes) telecon with KAPL- flammability
li mit curve supplied by KAPL-in 10 days @ 3.5%
steam and 10.9% oxygen, can bum-KAPL agrees
with Tedesco radiolysis source term of 28-39 cubicfeet per day at 1000 psi. Appears now nearing burnthreshold but at present 4.7% steam and 4.8% oxygen, the mixture cannot bum. Not close to detonation range for 2 weeks or more-hydrogen and1141

oxygen are not recombining (in the bubble) becauseof low temperatures-in a nonboiling liquid regime,
gamma flux could cause recombination, effective
about 1 month after shutdown if oxygen and hydrogen dissolve in liquid. Autoignition is a strong function of amount of water vapor.
1605

Tedesco telecon to Mattson (notes)-answering six
questions posed by Mattson at 1050 hours-resultsof talking to Ernie Vernus of KAPL and Irv Pinkel ofNASA-KAPL agrees with conservative estimate of
28-39 cubic feet per day of hydrogen and oxgen at1000 psi by radiolysis (about 13 cubic feet per dayof oxygen). Approaching flammability now (5% mole
fraction of oxygen ® 4.7% mole fraction of steam).
Detonation limit 10 days to 2 weeks in future. Oxygen probably won't recombine, will stay free, might
be some recombination due to gamma flux. 20%
overpressure if burned at flammability limit. KAPL
had no evidence of spontaneous ignition underpresent conditions.
About 1625

Hendrie telecon to Thomburgh (Comm. transcript)discussion of evacuation and NRC press conference
earlier that afternoon. Hendrie mentions hydrogen
flammability problem and notes that it is not near
term; "not something that we have to deal with here
i mmediately."p.m.

Hazelton (recollection) and John Weeks, BNL(memo)-l estimate that as much as 3200 lbs. of Zr
may have reacted with water to produce the hydrogen bubble, assuming it occupied 750 cu. ft. at
500"F and 1000 psi, as stated by Hazelton. Thissuggests that over 10% of the Zircaloy cladding in
the core was converted to oxide by reaction withthe water. Whether or not the remaining Zircaloy
could act to remove hydrogen from the water by
hydride formation is not clear. However, the hydrogen overpressure during normal PWR operation
does not cause significant hydriding of the fuel cladding so that hydrogen removal from the bubble bythis mechanism seems unlikely. This hydrogen(10-50cc STP/kg H 2O) amounts to a maximum of
3.24 lb. in the primary coolant (329,200 kg) soclearly, the majority of the hydrogen bubble camefrom some other source such as Zr-H 20 reactions,
if the bubble was as large as described by Hazetton
on March 31,1979.

About 1800

Milstead (memo)- We contacted KAPL again on
March 31, sometime after 6:00 p.m. KAPL recommended that we not try to bleed the bubble from the
RCS to the containment but that we continue to degas while maintaining RCS pressure. They felt there
was sufficient likelihood of oxygen recombination in
the reactor coolant to continue degassing thecoolant through the makeup system rather thanrelease the bubble to the containment.
1800

Tedesco (notes)- update hydrogen/oxygen calcul ations with new measurement of 880 cubic footbubble at 875 psi. Result is 5.8% mole fraction oxygen and 4.3% mole fraction steam at this time.
(According to flammability limit curve drawn by
Tedesco ® 1600 hrs (notes), this is right on theburn threshhold.) KAPL prefers to try gamma induced recombination in the core and vessel rather
than bleeding hydrogen into containment where oxygen concentration is high.
Berlinger (recollection)- Lauben and Berlinger (atsite) were asked by Stello to provide Stello and Matt
Taylor with general information on hydrogen/air
flammability and detonation limits. Information wastransmitted to Taylor and Stello including 4% flammability limit and 8% detonation limit (most probably
16% at TMI conditions). These figures were off the
top of the head best estimates based on our previous experience in combustion processes. Stello
was advised to contact Dr. Bernard Lewis (Pittsburgh, Pa.) as a known authority in this area.
1845

Noonan telecon to Mattson (notes)-vessel explosion calculation by consultant Merriman says
stoichiometric burn of hydrogen and oxygen (worstcase) yields 20,000 psi overpressure. B&W puts ineffect of water vapor and calculates 7850 psi totalpressure and accounting for enriched hydrogen
reduces to 3000-4000 psi. Estimate 11,000 psi tofail bolts, 12,000 psi to fail head (all static pressures,
dynamic could be better or worse).
2023

Associated Press editor's advisory (Columbia Journalism Review)-Urgent (with nuclear) the NRC now
says the gas bubble atop the nuclear reactor atThree Mile Island shows signs of becoming potentially explosive. A story upcoming.... (Later press
1142

accounts say the mixture is now two to three percent oxygen and could be potentially explosive inabout two days when it reaches five percent.) AP
apparently relied upon three sources in the 2200 in
the NRC staff - Frank Ingram, Ed Case, and an
anonymous source. Later on, Denton advised thepress at 2130 and again at about 2200 in the
Governor's press conference in Harrisburg that the
bubble was two percent oxygen, could become
flammable at 8 percent, explosive at 16 percent, andthere were 12 days before an explosion was possible.
Evening

Denton (memo)- I was subsequently (throughout
Saturday) briefed often by Chairman Hendrie and by
i ndividuals in the IRC on oxygen evolution estimates
and the flammability and detonation limits forhydrogen-oxygen mixtures. The estimates and limits varied with time throughout Saturday. In my
meeting with the Governor and in press conferences on Saturday night, I relied upon the most recent estimates obtained by phone from Chairman
Hendrie prior to leaving the site for Harrisburg.
My concerns were considerably heightened by
the AP story and I returned to the site to determine
if our perception of the situation had in fact changed
and asked that plans be developed for the possibility that the bubble could not be removed in the next
few days.

Early evening

Stello (memo)- Sometime Saturday, I had a callfrom someone in the White House inquiring about
the AP story that had been released. I indicatedthat I did not know the facts regarding that issue
and since there was a reference to statements
made by Frank Ingram, I suggested the story wasmost likely released from Bethesda and referred thecaller to the Operations Center in Bethesda. I cannot fix the time, but believe it was probably lateafternoon or early evening, Saturday. Shortly after
the telephone call referred to above, I recall speaki ng to Mr. Case in Bethesda, trying to find out thebasis for the concern over the hydrogen bubble.
This phone conversation provided me with the first
insights to the concerns held by personnel in
Bethesda. I believe I indicated that I did not sharethe same concern at that time.
Novak (memo)- With regard to any discussions I
had concerning the potential for a hydrogen explosion inside the reactor vessel, the only conversation

I had occurred the evening of March 31. The discussion took place between V. Stello and myself at
the NRC trailer complex at TMI. At the time Stello
i nformed me of a concern staff personnel in Bethesda had regarding the potential for a hydrogen explosion inside the reactor vessel. I recall Stello mentioning he did not believe the concern was real but
was unable to convince Bethesda staff personnel tochange their view.

Novak (memo)- I n reviewing the notes that wereavailable in the IRC, there was indication that B&W
had discussed free oxygen after 10:00 p.m. on
March 31, 1979. I discussed these notes with Don
Davis, formerly of the staff, and he does recall discussions between staff personnel with regard to theamount of oxygen that might be present in the gas
bubble. He stated that it was possible he had discussions with B&W (Nitti) regarding this concern.
Don Davis also thought that Steve Hanauer was thestaff member with whom he had these discussions.
I talked to Steve Hanauer on this subject and henoted that he first arrived at the incident center at
2:00 a.m. on March 31 and recalls discussions with
Davis regarding hydrogen solubility but none withregard to oxygen. (Ed. note-The conversations
described here by Novak were held by him recently,
not at the time of the accident.)

Evening

Stello (memo)- During the evening of Saturday,

March 31, and morning hours of April 1, I asked Mat
Taylor to look into the hydrogen problem from thepoint of view of assuring the need to start the containment atmosphere hydrogen recombiner and thepossibility of adding oxygen to the hydrogen bubble
believed to be inside the reactor vessel, such that aburn or explosion of a hydrogen-oxygen (mixture)might result.

Berlinger (recollection)- Lauben and Berlinger (atdinner) discussed the possibility for a hydrogen explosion in the reactor vessel. We concluded, basedon available information, that the probability of a hydrogen explosion in the reactor vessel was very remote since oxygen levels in the reactor vessel
would have been depleted during cladding oxidation.
The effects of radiolysis were unknown at that time.

told by Noonan that Dr. Norman Slagg could do authoritative vessel explosion calculations. Asked
Noonan to get the work started that night.
Mattson (recollection and IRC voice transcripts)-

About 2000

2230

M. Taylor (memo)-received verbal request from V.

Stello to give thought and analysis to following
matters and to advise him on these before shift end:

Levine telecon to Mattson (notes)-INEL says now

about 2% oxygen in RCS, oxygen being evolved atabout 1% per day. Using Cooper data scaled to
TMI-2 decay power level, 12 days required from 10hours after start of accident until mixture reaches
6% oxygen level, probably no detonation source in
the RCS. Ritzman still thinking and working with
AVCO experts.

1. Possible "what if" system scenarios and possible
consequence outcomes plus best action coursesthat might be followed,
2. Try to make hydrogen balance calculations toestimate zirconium-water reaction magnitudes
and where hydrogen sources might be,
3. Give best judgment on whether or not hydrogen
explosion in vessel should be of worrying concern.

2200-2400

M. Taylor (memo)-in TMI-2 control room participat-

Here it should be noted that Taylor recalls discussing with Stello the Taylor estimate of 1.4 SCF ofhydrogen per hour (see 2200 hours on March 29).
The specific time on March 31 when this information
was discussed with Stello is not recalled. It is believed to have been during the latter part of the priorshift, sometime in the am, e.g., 0400-0800.

ed with V. Benaroya et al., on procedures review
and progress toward hook-up of the containmenthydrogen recombiners.
Sunday, April 1

About 0100

Murley (memo)-Some time after midnight on Sun-

2200

day morning, I went to the Incident Response
Center where Roger Mattson asked what we were
finding. I told him that the picture on oxygen concentration was confused, but that a conservative
estimate seemed to be that the oxygen concentra-

Anonymous (perhaps Don Davis) notes in IRC ofconversation with Jim Taylor on miscellaneous
topics- B&W feels that hydrogen recombination istaking place under gamma flux.

1143

tion in the hydrogen bubble was increasing at therate of 1% per day after reactor scram.
About 0130

Eisenhut (notes) telecon Ross (corresponding notesfrom Ross at site appear to indicate Mattson onphone also)- using makeup adds oxygen, maybe
replace air with nitrogen or carbon dioxide.
Eisenhut notes say Ross told explosive potential ofhydrogen/oxygen bubble was:
2-3% oxygen now in bubble
1% oxygen added per day
6-8% oxygen flammability limit
12% oxygen detonation limit
Have never seen spontaneous detonation.

0200

Tedesco (recollection) telecon with Taylor at sitediscussed hydrogen calculations; Tedesco indicatedresults obtained in Bethesda and given to site wereconservative and there was no immediate concern
with detonation.
About 0200

M. Taylor (memo)-contacted R. Tedesco (Bethesda) to find out what were latest assessments from
Bethesda regarding reactor vessel hydrogen andoxygen concentrations and explosion potentials.
Tedesco advised that most recent Bethesda calcul ations indicated the following concentrations in thereactor vessel (from notes):'

46.5 ft', oxygen (radiolysis)' 103 ft', hydrogen (radiolysis)',615 ft', hydrogen (Zr-water reaction)'v765 ft' (approximates bubble size estimate)

Tedesco also relayed some KAPL info on
flammable/detonable concentrations, and he pointed out present estimates indicated that there would
be approximately 10 days before explosive concentrations would be reached in the reactor vessel.
Taylor recalls Tedesco mentioned some boundingkinds of calculations on the effect of an explosion in
the reactor vessel where explosive pressures on
the order of 14,000 psi might be experienced. Taylor recalls suggesting again that HQ-IRC make contact with Dr. Zittel of ORNL for added insights on radiolysis behavior.
0300

Anonymous notes in IRC call from Olshinski at siterelays bubble measurement procedure being usedby Met Ed.
1144

0430

Eisenhut (notes) telecon with Dr. Marty Haas
Univ. of Buffalo-KAPL document as source of hydrogen solubility, detonation limits and peak overpressures. Eisenhut "passed info to bubble groupof staff."
About 0800

M. Taylor (memo)-advised V. Stello as to the following:
1. Hydrogen balance estimates were very rough,but these suggested a Zr-water reaction magnitude in the range of 25-32% [Note these estimates depended on assumptions about reactor
vessel bubble size and on the nature (local vs.
free-field) of the hydrogen deflagration observedat roughly 9-10 hours into the accident. Review
of pressure recorder spikes suggested local as
opposed to a free-field deflagration in containment.]
2. Personal judgment was that he (V. Stello) should
not worry about the explosion in the reactor
vessel since this was considered to be an
exceedingly remote possibility. [Note that due tothe press of shift change activities, the reasoning
underlying this personal judgment by M. Taylor
was not fully explained to V. Stello. Reasoning
relied importantly on recall of the ORNL radiolytic
work done for AEC approximately 10 years ago.
This work covered various post-accident coolant
chemistries, temperature conditions and system
configurations-flowing and static. Importantly,
those experiments where basic ph chemistries
were involved led to highest hydrogen yields approaching 7-8 atmospheres (recall) before
recombination terminated the net yield of hydrogen and oxygen by radiolysis (i.e., back and forward reactions were equal). This suggested no
net evolution of oxygen should be anticipated at
the actual TMI-2 reactor vessel conditions of 900
to 1000 psi. Further, the ORNL work with thesebasic coolant chemistries were assumed to approximate the TMI conditions where NaOH had
actually been introduced early in the accident.
This ORNL work of approximately 10 years ago
also indicated an interesting oxygen scavenging
behavior,
i. e.
oxygen evolution was notstoichiometric with hydrogen. This behavior
further suggested that any free oxygen (if it possibly existed in the bubble space inasmuch as
this might be attributable to the use of nondegassed water from the borated water storagetank) could be subject to the same scavenging

Budnitz says that microscopically, at almost any
temperature, the mixture might possibly ignite on
sharp surfaces so unclear whether KAPL and others are right about no spontaneous ignition at flammability limit. Tom Murley quotes Picattiny Arsenal(Slagg) as source on hydrogen flammability.

behavior. These above factors when taken withthe realization that the hydrogen reducing environment at TMI probably exceeded, by far, theroutine reducing environment usually used in
PWRs, plus the need for an ignition source, led toa judgment that a hydrogen explosion in thereactor vessel was of an extremely remote possibility.]
3. Tedesco's estimates were described.
4. Some possible "what if" scenarios and thoughts
were available for discussion when Stello had
further time and need to consider these.

0900

Berlinger (recollection)-Berlinger at site was asked
by Stello/Vollmer to calculate the change in containment hydrogen concentration which would occur
i f the RCS bubble, assumed to be all hydrogen at1000 to 1500 ft 3 , 875 psia and 300°F, was vented tocontainment. The analysis results were transmitted
to Stello/Vollmer and left in the NRR trailer files.
The results indicated a change in containment hydrogen concentration from 1.9% to 3.5%. Since thehydrogen concentration in containment was stabilizing at 2% the possibility of a containment hydrogen
explosion appeared remote, unless conditions
changed dramatically due to radiolysis.

Early a.m.

Stello (memo)-This issue (hydrogen combustion inreactor vessel) was discussed on and off during that
period (late March 30 and early April 1) and my best
recollection is that it was concluded that no net oxygen would evolve as a result of radiolysis since theback reaction due to the hydrogen overpressure
would force all of the oxygen produced to berecombined with the hydrogen to form water.
Neglecting the hydrogen overpressure, results ofanalysis by Mat Taylor suggested an oxygen evolution rate of about 30 standard cubic feet per day
could occur. With this evolution rate, it would takemany weeks to reach a flammable mixture. Mat
Taylor's advice to me was that I should not haveany concerns for the potential of a hydrogen burnor explosion within the reactor vessel.
I believe I also requested others to seek information from representatives of various companies thatwere located at the site. I believe John Collins returned with some information that suggested GPU(and possibly B&W) also did not consider the hydrogen in the vessel to present a hazard from a burn or
explosive nature.

a.m.

0840

Eisenhut (notes) telecon Vollmer at site-no firm info
(at site) on gas in reactor vessel; Taylor thinks not
flammable.
About 0840

Eisenhut (notes) conversation with MattsonRitzmann using ORNL and AVCO and Tedesco usi ng KAPL and Westinghouse estimate:

Murley (memo)-On Sunday morning someone suggested that I collect information on what pressures
could be generated if there were a hydrogen explosion in the pressure vessel. I found that Vince
Noonan of NRR was the focus in NRC for theseanalyses and I therefore was involved only peripherally.
I received information that Dr. Norman Slagg ofPicattiny Arsenal had made calculations showing a
sharp peak pressure of 12,600 psi for the case of adetonation of a 1000 cu. ft. bubble containing a mixture of 83% hydrogen, 12% oxygen and 5% steam.
This pressure appeared to be consistent with information received by Bob Budnitz from Dr. Bernard
Lewis of Pittsburgh that pressures could reach 5times initial pressure for deflagration and 13-14
times initial pressure for detonation (where
Po=1000 psi is the pressure of the bubble and thesystem initially).
This information was passed on to Vince Noonan
and I had little further involvement after Sunday
afternoon.
0900

Mattson (notes) telecon Dr. Norman Slagg of Picattiny Arsenal-12% oxygen, 5% steam, 83% hydrogen yields 12,600 psi "striking the wall." IRC voice
transcripts indicate Mattson and Noonan agreed tohave Slagg begin these calculations the previous
evening.

oxygen production rate 1% per day by radiolysis,
5% oxygen in pure hydrogen is flammability,
12% oxygen in pure hydrogen is detonation,
impurities raise these values, but Budnitz says
not much.

1145

0915

Mattson (notes) conversation with Murley, Levine,
Budnitz- preparing for departure to TMI with Hendrie; night shift briefing Mattson who has just returned to the IRC. Group reached decision on hydrogen explosion potential for transmittal by Mattson to Denton and Stello at site. Levine or Murleyadvised Mattson that Ritzmann had talked to B&W,
that the INEL use of Cooper data was uncertain, andthat the INEL estimate was to be believed more thantheoretical approach of Ritzmann. Group decided
upon following:
5% oxygen realistic flammability limit
11% oxygen realistic detonation limit
900"F spontaneous combustion threshold
1% per day oxygen production rate
5% oxygen content @ Sunday a.m.
Levine (recollection)- recalls that the group agreed
that these values for the rate of oxygen production
and the present oxygen content were upper boundestimates.
Murley (memo)- Later that morning (around 9:00
a.m.) Roger Mattson met with Saul Levine, Bob Budnitz and me at the IRC prior to leaving for the TMI
site. Chairman Hendrie, Commissioner Gilinsky andCommissioner Kennedy came and went throughout
this short meeting as I recall. Mattson summarized
the following information as the distillation of all of
the input he had received.
Flammability limit > 5% oxygen in pure hydrogen
Detonation limit > 12% oxygen in pure hydrogen
Combustion limit > 18% oxygen in pure steam
Oxygen production rate -1% oxygen per day inhydrogen/oxygen bubble
Current oxygen concentration - 5% oxygen inhydrogen bubble
Budnitz (notes)-Meeting with Mattson, Levine, Murley, and me. Mattson was about to depart for the
TMI-2 site by car with Chairman Hendrie, and heasked for an up-to-date, agreed-upon set of
numbers about the "bubble." We all agreed on thefollowing set of numbers, which were written down
by me and are in my notes.
1. Best estimate for flammability limit, pure oxygeni n pure hydrogen at 1000 psi=5% oxygen.

2. Best estimate for detonation limit, pure oxygen inpure hydrogen at 1000 psi=12% oxygen.

We also agreed that the best estimate for total
production of oxygen from radiolysis in the TMI
vessel would be about 5% oxygen (as fraction of
bubble) as of the present time if there were norecombination. We also discussed the fact that oth1146

er people among our NRC contractors were actively
calculating the true oxygen which would be smaller
than the radiolysis production rate because ofchemical recombination. We discussed together
that the 5% oxygen/hydrogen ratio was a pessimistic estimate, in the sense that the actual value wassurely not larger and might be smaller. I remember
us discussing how probable it was that the number
would ultimately turn out to be much smaller. I
remember that we were not yet sure that a smaller
number would result from the accurate calculations
underway at that time. Some differences of opinion
existed as to how "sure" we were of what estimatesby which experts, and Mr. Levine was more confident than the others that the oxygen would not be a
problem.
I remember that Commissioner Bradford camei nto our brief meeting just as it was breaking up, andwe acquainted him with our discussion.
a.m.

Lanning (memo)- Bob Jones (B&W) requested
second test in Semiscale. Suggested doubling sizeof bubble and include HPI flow based on B&W's
contingency plan for depressurization.
Remainder of day spent primarily on coordinating
Semiscale test results and second test.
Provided answers to various Labs and individuals
who were working on hydrogen explosion, degassi ng, radiolysis and recombination of hydrogen andoxygen (no notes available).
Tedesco (recollection) telecon to K. Woodward of
Pickard and Lowe- called on request of Murley.
Discussed results of radiolysis calculations in containment. Recall that Woodward's estimates werehigh compared to those of NRC staff.
Butler telecon to Tedesco (recollection)- Butler
gave results of staff discussion with I. Pinkel abouthydrogen in containment.
About 1200

Mattson (recollection) meeting with Hendrie, Stello
and Denton at Middletown airport-relayed information agreed to at IRC with Murley, Budnitz andLevine before departure to site. Stello strongly believed IRC was wrong and that oxygen was being
recombined because of high hydrogen concentration. Mattson and Stello had not talked earlier because of the press of other assignments and different working schedules and agreed that the twodifferent points of view needed rapid resolution.

President Carter was briefed by Denton and Stello
about the hydrogen explosion problem and was told
about the uncertainty of staff conclusions at thatti me.
p. m.

Levine (memo)-I spoke with James Proctor of theNaval Surface Weapons Center about the effects ofa hydrogen explosion on vessel integrity. He said
the cylindrical portion of the vessel would be subj ected to about 6% strain, which should not break it,
and that it would also be subjected to a lifting force
8of about 1.5 x 10 l bs. He could not calculate
whether the main loop piping could hold the vessel
down when subjected to this force, since he did nothave detailed information on plant layout.
MiddayBudnitz (memo)- On Sunday morning, on referral
from Harry Petschek of AVCO Everett, I reached Dr.
Bernard Lewis of Combustion and Explosives
Research, Inc., of Pittsburgh.
He acknowledged that he had much expertise on
the combustibility of hydrogen and oxygen; indeed,
he is the coauthor of a definitive text book on thissubject. He and an assistant, reached at home on
Sunday morning, worked through that day and partof Monday, April 2, and gave important advice on
the issues that governed the physical behavior ofhydrogen and oxygen burning in conditions such aswere thought to exist within the primary vessel at
TMI. I was Lewis' sole NRC contact during thisperiod. He gave information about the mixture ofoxygen in pure hydrogen that would be a combustion threshold, talked at length to me about the physical difference between combustion and explosion,
and what would be the impact of gaseous impurities
i ncluding steam. He reported back his preliminary
conclusions sometime after midday on Sunday, April
1, and his final conclusions in midmorning of Monday, April 2. He calculated pressure ratios (pressure within a fast burning situation vs. starting pressure), detonation thesholds, heat release, flame temperatures, and other parameters. His insight was
valuable in providing a perspective on which parameters were, and which were not, important in modifying the result of what was easily calculated using
approximations. Thus the approximate calculations
were refined, and the refinements were better understood by me.
Dr. Lewis' best estimate about midday Sunday
was that the "pressure pulse" would be about 5500
psi for a fast combustion event (requires above
about 5% oxygen) and about 13 000 psi for an ex-

plosion (requires above about 12% oxygen). On
Monday, Dr. Lewis revised the 5500 estimate
downward to about 3200 psi.
Lanning (memo)-Requested and provided information to INEL to perform second test in Semiscale.
Obtained plan from B&W on proposed HPI flows
versus time. Coordinated information to Labs concerning hydrogen explosion, degassing, radiolysis
and recombination of hydrogen and oxygen.

Budnitz (recollection)-By about midday on Sunday,
there emerged a reasonably reliable consensus
among our outside expert contacts about two questions: how large the short pressure pulse might be
if a fast combustion event were to occur inside the
TMI primary vessel, and at what pressure the vessel
would approach its "yield point" and its "ultimate"point, thereby compromising the integrity of the primary system. I was responsible for coordinating theformer concern and Tom Murley brought together
the information on the latter.
Our general conclusion at that time was that, forabout 1000 cubic feet of pure hydrogen with oxygen
just above the threshold value of about 5% at 1000
psi, the "pressure pulse" would be about 5500 psi.
This came mainly from Dr. Lewis of Pittsburgh (onMonday, Dr. Lewis revised his best estimate downward to about 3200 psi). The "yield point" of thevessel, according to Tom Murley, seemed to becoming out at about 6000 psi. Both of thesenumbers had rather large uncertainties, of which I
and Murley were acutely aware.
I discussed these rough results with Saul Levine,
who suggested that I tell Chairman Hendrie, who
was at the TMI site. I spoke by phone with Hendrieand relayed this to him, expressing the uncertainties
to him as well as the numerical best estimates. This
call occurred just prior to my meeting with the otherCommissioners, which began at 1350.
I was requested to give, and did give a briefing on
the same subject to the other four NRC Commissioners, all gathered together in the NRC Incident
Response Center. This 15-minute briefing was attended also by Len Bickwit (NRC General Counsel),and about 15 other NRC people. This briefing canbe found verbatim in the Commission transcripts.
About 1345

Commission Meeting at IRC with Budnitz (Comm.
transcript pp. 94-116)- Commissioners Gilinsky,
Kennedy, Bradford and Ahearne discuss evacuation
scenarios for hydrogen combustion in reactor
vessel (pp. 94-99). Thompson relays info from IRC
staff that mixture is then 5% oxygen and flammable.
Budnitz gives briefing on current assessment by IRC
1147

i n solution which closer matched the RCS sample
obtained on March 30, 1979, and a best estimate G
Value of 0.33 molecules/100 EV. Our best estimate
calculations compared favorably with estimates ofpotential hydrogen growth rate calculated by the
Office of Research.

staff of bubble situation (pp. 100-116). He concludes that if a fast hydrogen burn were to be initiated, vessel integrity would be compromised.
Didn't know of any initiation mechanisms. Budnitz
says that during burn, pressure will increase by afactor of 5.5. Burn will last 10-20 msec. If 1000 psi
before burn, pressure during burn will be very close
to yield strength of the pressure vessel. A little over
10% oxygen is needed to sustain detonation. In detonation, pressure is increased by a factor of 13.5the pressure vessel would be lost. Budnitz also
points out that if the temperature rises to 680°F, themixture will go off spontaneously-no ignition
source would be needed.

p.m.

cussed calculations of radiolysis in containment using TID source team. Levine advised that estimatesappeared high because of use of radiation source
term larger than TMI-2 sample analysis. Tedesco
directed staff to revise calculation to approximate
TMI-2.
Levine telecon to Tedesco (recollection)- Dis-

Early p.m.

Milstead (memo)- On Sunday afternoon (April 1,

1979), KAPL reported to the NRC staff in Bethesda
the results of analysis performed with Naval Reactor
water chemistry code. Using the code and assuming 10% of the core in boiling KAPL predicted a bubble growth rate of 0.4 ft3 /day. If it were assumed
the entire core was in boiling the growth rate could
be 8 ft 3/day. The reason for this low bubble growth
was that total recombination of the oxygen formedby radiolysis in the reactor coolant was predicted
due to the large amount of hydrogen in solution.
KAPL's analysis indicated the bubble contents to bealmost entirely hydrogen (from metal-water reaction) and indicated a net radiolysis of zero in thereactor coolant for most of the transient. On thisbasis, it was concluded that the bubble had notreached a flammable oxygen content and would not
be expected to.
KAPL indicated that effective oxygen recombination in the reactor coolant would be predicted forhydrogen concentrations in the coolant greater than
0.1 scc/kg. They suggested the degassing process
be continued and a minimum concentration of 1.0
scc/kg be maintained in the reactor coolant toprevent net radiolysis in the reactor vessel.
On Sunday afternoon (April 1, 1979), we peformeda series of COGAP analyses assuming radiolysis in
the containment sump only and no recombination ofoxygen. Our analysis indicated 5-day hydrogenrates from about 600 scf/day
production(0.03%/day by volume in the containment) to about
3600 scf/day (0.21%/day in containment). The
3600 scf/day rate was calculated using the conservative assumptions of Regulatory Guide 1.7 (i.e., G
Value of 0.5 molecules/100 EV and a TID release incontainment). Our best estimate calculations resulted in 5-day hydrogen growth rates of 600 to 1000
scf/day (0.03%/day to 0.05%/day in containment).
These analyses used estimates of fission products
1148

Stello (memo)-l recall outlining for the Chairman (atthe site) the basis upon which I did not believe thehydrogen bubble in the reactor vessel could reachan explosive potential. Basically, I reiterated theresults of the reasoning we (at the site) had gone
through that morning and previous night. I requested the Chairman that before any further action betaken on this issue, that I be given some time tocontact some other experts to see if I could get additional technical information.
Mattson (recollection)- worked at site command

post following briefing of President to resolve differences in IRC and site positions on oxygen generation by radiolysis.
About 1430

Benaroya (recollection)- After working the grave-yard shift, woke-up in the motel room thinking about
the hydrogen-oxygen problem in the gas bubble.
He tried to call the NRC command center in the
trailer, but all phones were busy. He finally decided
to call the TMI-2 control room and got in touch with
Norm Lauben at around 1500. Benaroya explainedthat normally a hydrogen concentration of 20-40
cc/kg of water is kept in the primary system to eli minate free oxygen. At the pressure and temperature that existed in the primary system, in the radiation field, 20 cc of hydrogen per kilogram of water isenough to push the reaction towards recombination.
Since we had a large excess of hydrogen, it wasvery unlikely that any free oxygen would be present
i n the gas bubble. Benaroya asked that this information be relayed to the NRC trailer. N. Lauben
called back V. Benaroya at the motel saying that hehad relayed the information to Mattson, and Mattson
told him that this was being calculated in Bethesda.

p.m.

Rosztoczy (memo and recollection)-On April 1 andApril 2 of 1979 Brian Sheron, Garry Holahan andmyself performed gas bubble size calculations for
TMI-2. The work was done on Don Davis' request,
who worked in the Bethesda Emergency Center at
the time. Frank Almeter (EB) was called in to help.
We also had telephone conversations with Ledyard
Marsh (DOR) and Paul Cohen (retired from Westinghouse) who is a well-known expert on water chemistry for nuclear plants. Mr. Cohen was very helpful.
We were asked on April 1 p.m. to review themethod used by B&W for determining bubble size.
Our conclusion was that the method had two errors:a rather major error in the solubility term by omitting
the correction factor to account for elevated pressure and temperature and a small error in the multiplier in front of the equation. Both of these are documented in the attached memo prepared by B.
Sheron dated April 5, 1979. During the course of
our work we also recognized that the anomalous
behavior of the letdown line during the bubble
measurements introduced large uncertainties in the
bubble size. We recommended, therefore, to close
the letdown line during measurements.
All of this information was communicated to Davison the evening of April 1 and early a.m. April 2. My
understanding is that the recommendation to close
the letdown line during measurements was followed.
All measurements taken late on April 1 and early on
April 2 had the line closed and showed a significantly smaller bubble size than previous measurements.
1500

Steno (notes)-On April 1, 1979, 3:00 p.m., I requested Bettis Laboratory to evaluate the potential for radiolysis contributing oxygen to the bubble over thereactor core. The following people participated in
the evaluation: Don Connors, Lou Bogar, Jim
Wright, Ken Vogel, and Bill Walker (KAPL).
The following information was provided and was
represented as the Bettis Laboratory position. A
report would be prepared if requested. I indicatedthat I would let them know if there was a need.

(a) The first question I asked them to consider was if
we assumed that the bubble over the reactor
core is 800 cubic feet, 1000 psi and 300°F is it
possible for oxygen to be added to the bubble bya radiolysis process?

Answer.

Their best estimate analysis would indicate that no oxygen would be added to the bubble. The analysis is derived from considering
Henry's law; they would expect that under theconditions there would be 900 cc per kilogram

1149

STP of hydrogen going into the water. Based on
experimentally derived information with a concentration of 2 cc's per kilogram at STP in water,
radiolysis would be prevented. The experimental
information was derived from data collected in
the S7G prototype program and a reference iscited to data dating back to 1943.

(b) l requested Bettis to provide me with an estimateof the radiolysis rate assuming there was no hydrogen over-pressure in the bubble.
Answer: Assuming no recombination was permitted, they calculate that approximately 8.4 cu. ft.
per day of oxygen radiolysis rate of 29.2 cu. ft.
per day at STP. The recombination rate wasbased on a g-factor that was experimentally
determined from S7G and boiling water reactor
data.

These data were stated to be conservative relative to PWR conditions. The g-factor used was 0.7
molecules of oxygen per 100 EV of gamma absorbed, at 1.5 x 10 9 MEV of gammas per squarecentimeter per second. They assumed that 1/10 of
the gammas generated in the core are absorbed in
the core and that 1/15 of the gammas absorbed in
the core are absorbed by water. They have had informal discussions with people like KAPL who independently determined a radiolysis rate in thesame ballpark (estimated to be approximately 65 cu.
ft. per day at STP). Dr. Connors is going to ask
KAPL for their view to see if their evaluation of the
problem is the same.
About 1500

Stello (notes)-On April 1 at about 3:00 p.m., I requested the same information of the General Electric Company (commercial) as I did from Bettis Laboratories. The GE response was that it is theoretically possible that oxygen could be added to a hydrogen bubble over the reactor core. However,they did not consider this would be likely and concluded that they believe that an equilibrium condition
may now be present. They calculated a bounding
number for the amount of radiolysis that could takeplace assuming no hydrogen overpressure. They
estimated that the bounding number is 10 cubic feetper hour at STP but believe this was too conservative since it was based on BWR data (NEDE-13148
Title KRB Radiolysis Test, Nov. 1970) and that no
credit was given for the effects of a back reaction
and that the real number is much lower. They
speculated that perhaps there is no net oxygen added. The following people participated in theevaluation: Cliff Kent, Jerry Jacobsen, Pat Marriott,
Manny Ziegler, and Don Rockwell.

Stello (memo)- ( After) I obtained that information(from Bettis and GE) ... (I presented it) to the Chairman. I believe he was persuaded that we need nothave a concern for either a burn or explosion of thehydrogen in the reactor vessel. Following our discussion, he placed some telephone calls to Washi ngton to discuss this information with fellow
Commissioner(s).
p.m.

Levine (memo)-I also spoke with Harold Schwarz
of BNL, I believe on Sunday afternoon, April 1. He
said that he believed that not only would oxygen not
be accumulating in the hydrogen bubble, but thatwhatever hydrogen and oxygen were in the bubble
would be depleted at fairly rapid rates. He said that
he would calculate the rates and call me later on
Sunday. On Sunday evening he told us that he hadcompleted his calculations which confirmed that oxygen could not accumulate in the bubble and that it
would in fact be depleted.
About 1500

Budnitz (memo)-On referral from Dr. H. J. Kouts ofBrookhaven, Saul Levine and I contacted Dr. Harold
A. Schwarz of Brookhaven. I am not sure when he
was first reached by Levine, but both Levine and I
talked to Dr. Schwarz at various times during theweekend.
Dr. Schwarz worked April 1 (beginning about 3:00
p.m.) on calculating the production and recombination rates of oxygen in the TMI primary coolant water. He did these calculations at home mostly, I
think; telephone contacts with him during the weekend were at his home. He reported on the considerations that were involved in his calculations,and ultimately showed definitively that oxygen generation from radiolysis would not result in much oxygen in the gas phase, because of the recombination reaction with the assumed large hydrogen gas
overpressure and the associated dissolved hydrogen. We were apprised of the preliminary results of
Dr. Schwarz' work on Sunday afternoon, April 1, in
my memory, but it was not firmed up until sometimein the evening that day. Dr. Schwarz filed adescription of his calculation with NRC on April 24.
The April 24 note to me describes well that the calculation is tricky and involves tracking down anumber of chemical parameters and calculating
several reaction rates. Impurities within the TMI
cooling water were important enough that information taken from conditions of normal reactor operations could not be relied upon.
1150

1552

Commission meeting at IRC (Comm. transcript, pp.
131-144)- Commissioners Kennedy, Bradford, andAhearne discuss evacuation scenarios for hydrogen
combustion in reactor vessel. Apparently reachinga consensus to recommmend evacuation that afternoon because of combustion potential. They expressed concern over obvious differences in data
coming from the staff. They decided to advise Hendrie at site that they were concerned there may beneed to consider evacuation.
Kennedy andAhearne leave at 1617 hours to talk to Hendrie on
the telephone.
About 1620

Kennedy telecon with Hendrie (Ahearne recollection
and notes)-Kennedy relays to Chairman the adviceof the three Commissioners at Bethesda (Kennedy,
Bradford, Ahearne) that, based on Budnitz reports,
they recommend that, unless people on site havebetter technical information, NRC recommend
Governor Thornburgh advise a precautionary evacuation within two (2) miles of the plant. This would
be precautionary, just as the Friday evacuation advisory. Hendrie informs Kennedy that oxygen is not
a problem-the hydrogen in the water would capture the oxygen.
About 1700

Mattson (notes) telecon to IRC-B&W tells IRC there
is no oxygen in bubble. Salvatore of Westinghouseremembers Bettis data which says that excess hydrogen inhibits oxygen formation by radiolysis.
Ritzmann tells IRC that one to two percent per day
oxygen generation rate is with no accounting of inhibition, and hydrogen inhibits. Levine says to use
0.1% per day instead of earlier 1%. Levine also advises previous INEL estimate in error by factor of 10
too high.
1800

Mattson (notes) telecon with IRC- Budnitz reports
to Mattson that answers from experts range from 0
to 1% oxygen per day. Budnitz reports that Herb
Kouts of BNL thinks oxygen generation rate is small;
ph is an important parameter; revised INEL calculation says 1% oxygen is now present; current estimate of IRC is less than 1% oxygen; but still working
to finalize position.

About 1900

Mattson (recollection)- Mattson and Hendrie met
with Industry Advisory Group in Middletown National
Guard Armory. Ed Zebrowski of EPRI expresssed
strong dismay with NRC for having incorrectly
judged the hydrogen explosion potential by not
quickly understanding that oxygen could not be
evolved by radiolysis in a hydrogen rich environment.
Monday, April 2a.m.

Thadani (memo)-If my memory is correct, on Monday, April 2, I developed criteria (at the site) for therate of degassing and the process limits that were
to be maintained. Otherwise, degassing was to bediscontinued.

been underway for several days and the confidence
that can be placed in the bubble measurements.
Bubble Size
Encouraging signs that it is smaller than earlier
measurements indicated.

• measurements are better• degasifying thru recombination letdown seal
l eakage in pump

Bubble Content
Our present understanding of the gas evolution
and decay process says the rate of addition ofoxygen is not what we originally estimated.
There may be an equilibrium condition in which
there is little or no net generation of free oxygeni n the reactor or even recombination of any excess oxygen (i.e., either slightly positive, zero or
negative).
Combustion Limits
Our earlier estimates were conservative, butthere is some uncertainty in the available data, so
staying with the 5% and 11% limits.

About 1000

Lauben (recollection)- Radiophone from control
room to Mattson (recollection)-Lauben has been
following GPU bubble size measurement andanalysis. Expressed confidence that bubble size
was decreasing dramatically.

1115

Denton and Mattson press conference in Middletown (transcript)- Measurements show dramatic
decrease in bubble size; don't want to be stampeded into concurring bubble actually this small; certainly reason for optimism; oxygen generation rate
described yesterday by Denton was too conservative; oxygen evolution rate is much less than one
percent per day; we think it is safer than we didyesterday; hydrogen backpressure inhibited formation of oxygen by radiolysis.

1100

Mattson (notes) for Denton Press Briefing-For the
past several days we have been studying the potential hazard of the gas bubble in the reactor.
There has been concern that the bubble could
reach a flammable condition if oxygen were being
added to the hydrogen. Our earlier statement on
the effects of bubble flammability on the safety ofthe plant were primarily based on preliminary
theoretical analysis by the technical experts. Thereis also some experimental data for these conditions.
After several days of intensive consideration of the
problem by these experts, we now believe that thehazard of hydrogen burning in the reactor is notnearly as severe as earlier indicated. We havemuch higher confidence today that there is no nearterm hazard from hydrogen burning.
There is one piece of new information from theplant that contributes to our present state of cautious optimism in this area. Measurements of thesize of the bubble over the last 24 hours indicatethat it is not as large as originally estimated, and it
may be continuing to diminish. We are studying thisnew information closely to determine the effectiveness of the degasification process that has now

1200

NRC Preliminary Notification PNO-79-67H, Paragraph Two on Plant Status at 12 noon 4/2/79
states-Further analyses and consultations with experts have led to the development of a strong consensus that the net oxygen generation rate inside
the noncondensible bubble in the reactor is muchl ess than originally conservatively estimated. Also,
measurements at the plant appear to indicate thatthe volume of gases within the bubble is being significantly reduced. Further developments are being
closely followed to confirm these favorable indications.
MiddayLanning (memo)- Coordinated results of second
Semiscale test to B&W and IRC. B&W indicated1151

that they were going to revise HPI flow rates in contingency emergency plan to vent the bubble as theresult of tests. Discussed analytical predictions oftime period to vent bubble in comparison to Semiscale results.
Relocated from MNBB to East-West Towers.
Performed calculations of time period to degas using pressurizer spray. A lot of uncertainty existed
concerning flow rates in pressurizer surge andspray lines and makeup and purification system(coordinated with K. Parzewski).
1220

Commission meeting (Comm. transcript)- Hendrietells other Commissioners of the status of the bubble concern at site as described by Denton andMattson at 1100 press conference. Concern is very

considerably mitigated and on its way to not beingof concern much longer. There has not been any
substantial evolution of oxygen at anytime in thesystem.
2052

Nitti of B&W written opinion -on H2/02 bubble(memo Roy to Mattson) includes statementthat "A review of the postulated sequence of eventson March 28 lead us to conclude that there is no
significant amount of oxygen in the bubble that waspresent in the reactor coolant system of the Three
Mile Island Nuclear Plant.... (The) amount of dissolved hydrogen is approximately 50 times theamount required to suppress a net radiolytic generation of oxygen."1152

APPENDIX 111.5

NRC PROCEDURES FOR DECISION TO
RECOMMEND EVACUATION APRIL 1, 1979

NRC PROCEDURES FOR DECISION TO
RECOMMEND EVACUATION
Who Decides
1. Combination of consequences and times require
immediate initiation of evacuation: Senior NRC
Official on site recommends to Governor.
2. Unplanned event with substantial risk takes placeor is imminent or situation judged excessively risky but there is time for consultation. Senior
NRC Official notifies Governor and NRC HQ.
Chairman makes recommendation to Governor
after consulting with Commissioners if possible.
3. Planned event involving significant additional risk.
Chairman and Commissioners make recommendation.
Action Guidelines

a. Notify evacuation authorities two hours in advance (if possible) to standby for a possible evacuation.

b. Projected doses of 1 rem whole body or 5 rems
thyroid stay inside.
c. Projected doses of 5 rems whole body or 25 rems
thyroid mandatory evacuation of all persons.
Assumes general warning already that some formof evacuation may become necessary.
Weather

The table is based on a realistic prediction of theweather for the next few days, based on the April 1
forecast which would result in high doses at a given
distance. At the approach to decision time for evacuation, the appropriate meteorological condition will
be factored into the dose estimates to determine
the evacuation time, sectors, and distances for theevacuation.
NRC is predicting the dispersion characteristicsof the region for the currently measured meteorology as the incident progresses. Rain could lead tohigher local radioactivity levels.
1153

Event1. Loss of vitalfunction or unplanned leaks

ExamplesReactor Coolant
Pump Trip;

Expected Plant
Response

Depressurization
to go on RHR;
Leak in Auxili ary Building

2. Sequence leadi ng to Core Melt

3. Hydrogen flameor explosion
possible inside
reactor vessel
4. Evacuate or Lose
Control Room

Planned
Manuever

Releaseand Time

Restore function
within 1 hour

No significant
changeSwitch to Alternate
Function involving
Primary Coolant in
Auxiliary Building

Small leak lessthan 1 gal/hour

I

I

WarningTime

Large leak
50 gal/min

2 hours

Maintain Containment Integrity (likely)
with Containment
Cooling

Design Containment Leak Rate

4 hours

Containment
expected to BreachSignificant
release of corefission products

24 hours(ti me for containment
failure)Loss of offsite
power;

Loss of feedwater;

Unplanned Events*

Serious possibilityof failure to restore
a vital function

Evacuation
Scenario

Possibly precautionary
evac 2 mi; stay
i nside 5 mi
Possibly precautionary
evac 2 mi;stay inside
5 mi
Evac 2 mi
Stay inside
5 mi

See 2

Mixture in flammable
range

Evac 2 mi all
around and 5
mi, 90 0 sector,
stay inside 10 mi

Precautionary

Evac 5 mi all
around and 10
mile, 90°
sector, stay
i nside 15 mi

Precautionary

2 mi

Explosion; major
damageCore Melt See 2
Loss of Control
Treat like major
releaseProbability of losing
vital function
See releases underl oss of vitalfunction

Timing ofmanuever canbe set to provide as muchti me asnecessary

Evac 5allaround and nd nd 10
mi 90° sector,
stay inside
1 5 miles

Precautionary
evacuation 2
mi, stayi nside 5 mi
PLUS
See outcomesunder loss ofvital function.

'This table includes a number of assumptions about activity and weather, chosen realistically. In an actual release, therelease rate and weather should be evaluated as they are at the time, and the decision based on those values.

1154

Heat Generation

The reactor core is now quite cool compared tothe conventional design-basis calculations.

1. The reactor is new, so no fuel has more than 3months equivalent operation, compared to 1-2
years average for other plants.
2. The neutron chain reaction has been shut down
for over 4 days.

It should also be noted that the concrete basematof this plant is unusually thick.
As a result of the above differences, calculations
for this plant at this time predict that the core will
not melt its way through the containment.

Event 1-Sprays and Coolers Operative
Time=O

Flow stops; core and water start heatup

Time=100 min

Core starts to uncover

Time=200 min

Molten core is in lower head of reactor vessel; pressure is 2500 psia

Time=150 min
Time=210 min
Time=210 min

Core begins to melt

Reactor vessel fails; containment pressure goes to 25 psia

Hydrogen burns; containment pressure goes to 67 psia - Steam explosion possibility is a minor
consequence

CONTAINMENT SURVIVES (Failure assumed 130 psia)
Time=10 hours

Molten core has melted about 1 meter into basemat

CAUTION:

Keep sprays running
Keep water many feet over molten debris
WITHOUT RECOMBINERS Hydrogen continues to build up

Time=days

Major problem: handle hydrogen, oxygen; maintain containment integrity

BASEMAT SURVIVES
Event 1 Conclusion: This event should not produce major releases
Event 2-Sprays and Coolers Failed Before Flow Stops
Time=O to 210 min Same as Event 1: containment pressure is 25 psia
Time=810 min
Time=1 day

Containment pressure is 70 psia

Containment fails due to steam (mostly) overpressure, about 135 psia

CONTAINMENT FAILS
Event 2 Conclusion: This event leads to major releases.

1155

APPENDIX 111.6
ESSER REPORTA REPORT SUBMITTED BY GEORGE ESSER,PRESIDENT OF THE NATIONAL ACADEMY OF PUBLICADMINISTRATION, TO MITCHELL ROGOVIN (ROGOVIN,STERN, AND HUGE), DIRECTOR OF NRC THREE MILEISLAND SPECIAL INQUIRY GROUP

Prepared Under NRC-RFPA No. Res-79-210
I ntroduction

Purpose

1.0 The purpose of this report is to identify and assess major alternatives for governmental policies,
organizational structures, and actions in civilian nuclear reactor emergency management in the UnitedStates.
1.01 This report was prepared under a contract
between the National Academy of Public Administration, Washington, D.C., and the Nuclear Regulatory Commission (NRC-REPA No. Res-79-210, August
20,1979).

1.02 Under the contract, the National Academy of
Public Administration agreed to identify and evaluate
alternatives for governmental policies, organizational
structures, and actions in civilian nuclear reactor
emergency management. It agreed to review
present policies and practices in civilian nuclear
reactor emergency management, to review selected
experiences and practices of governmental agencies other than the Nuclear Regulatory Commission,and industries other than the nuclear power industry, and to identify alternatives to the present nuclear emergency system.
The Academy further agreed to submit a reportof findings on November 17, 1979, to Mitchell Rogovin, attorney, Rogovin, Stem, and Huge, who was
appointed director of the Nuclear Regulatory
1156

Commission-Three Mile Island Special Inquiry, by
the Commission, in May 1979.
This report is the result.

Development Authority
Albany, New York 12201
Robert P. YoungManager of Engineering
Martin Marietta Aluminum
6801 Rockledge Drive
Bethesda, Maryland 20034

The Panel

1.03 The Academy convened a panel to oversee
the project:
Dr. Harold L Enarson, Chairman
President
Ohio State University
164 West 17th Avenue
Columbus, Ohio 43219

Richard Pollock, Director
Critical Mass Energy Project
P.O. Box 1538
Washington, D.C. 20013

David Cohen, President
Common Cause
2030 M Street, N.W.
Washington, D.C. 20036

Staff

The following individuals served as staff

Project Director

Dr. James D. Carroll, Director
The Advanced Study Program
The Brookings Institution
Washington, D.C.

Lt. General Julian J. Ewell
6823 Melrose Drive
McLean, Virginia 22101
Thomas W. Fletcher
Senior Urban Management Specialist
Stanford Research Institute
333 Ravenswood
Menlo Park, California 94025

Dr. Harold Orlans
Senior Staff Member
National Academy of Public Administration
Dr. Erasmus Kkxnan
Senior Staff Member
National Academy of Public Administration
General DeWitt Armstrong, III
Consultant

Governor A. Linwood Holton
Vice President-General Counsel
American Council of Life Insurance
1850 K Street, N.W.
Washington, D.C. 20036

Mrs. Jean Levin
Research Associate

Dr. Gary A. Kreps
Associate Professor
Department of Sociology
College of William and Mary
Williamsburg, Virginia 23185
Dr. Chauncey Starr
Vice Chairman
Electric Power Research Institute3412 Hillview Avenue
Palo Alto, California 94304
Joseph C. Swidler
Leva, Hawes, Symington,
Martin and Oppenheimer
815 Connecticut Avenue, N.W.
Washington, D.C. 20006
Stephen O. Wilson, Manager
Office of Environmental Programs
New York State Energy Research andMrs. Janet Steigert
Research Associate
Mrs. Margaret Nolan
EditorMrs. Karen Webb
Production Supervisor

Editorial Experts, Inc., Alexandria, Virginia, assisted in the production of this report.
1.05 The panel met on September 9 and 10, 1979,
and identified issues for the staff to analyze.
The panel met on November 14 and 15,1979, andexpressed judgments on how the issues might be
resolved.
'At the time of his appointment, Dr. Carroty was Director,
Department of Public Administration, the Maxwell School,
Syracuse university.

1157

1.06 Part I of this report summarizes the conclusions of the panel on the issues.
Part II is a staff paper analyzing some of the issues and alternatives, and setting forth staff recommendations.
Part III is a staff paper describing the present
civilian nuclear reactor emergency planning andresponse "system" in the United States. While thispart follows I and II, individuals unfamiliar with thesystem may want to read Part III first.
Part IV describes emergency planning andresponse experience and practices in other government and industry sections in the United States.
This section is the source of some of the recommendations considered in Parts I and II.
Part V reviews the United States Army experience with civil emergencies. This also is a sourceof some of the recommendations in Parts I and II.
Limitations
1.07 The staff work for this project involved interviews with approximately 100 individuals in federal,state, and local governments, Congress, industry,law firms, public interest groups, and associations.
It also involved a review of several hundred documents from NRC and other federal agencies,
Congress, industry, public interest groups, and associations.
1.08 This project did not entail a de novo review ofthe events at Three Mile Island, and was specificallyli mited to emergency planning and action in the United States, although a brief review was made of documents describing practices in a few other countries.
1.09 Furthermore, this project analyzed only
selected issues. Because of time limitations, several
i ssues were not examined in this project.
1.10 Finally, this review was conducted in approximately six weeks. We believe that a permanent,
continuing effort to address the issues considered inthis report is needed-and that such an effort does
not now exist is a major failure of the research anddevelopment effort of NRC and the nuclear poweri ndustry. The base of knowledge from which we
operated was inadequate, and this report reflects
this inadequacy.
If nothing else is done as a result of this report, agreater effort should be made to increaseknowledge and understanding of emergency
preparedness for nuclear reactor accidents.

1158

PART IThe Conclusions of the Project Panel
1.00 The following is a summary of the panel's
conclusions with respect to government policy, organization, and action in civilian nuclear reactor
emergency management.
1.01 Three general views were expressed.
Some panel members expressed the view thatthe nuclear power industry is indispensable toAmerica's future. The safe operation of civilian nuclear power plants must and can be assured.
Some panel members expressed the view thatcivilian nuclear power is an unproven, hazardous
undertaking, the continuation of which cannot beassumed.
Several panel members expressed the view thatthe available evidence is insufficient to support a
judgment on whether civilian nuclear power is or
can be made safe.
The Nuclear Power Industry
2.01 I n over 20 years of civilian nuclear power
plant operation there have been few accidents thathave threatened public health and safety.2 (Thesupplemental views of Richard Pollock are presented at the end of Part I.)
2.02 The industry has been and should continue
to be responsible for the safety of plant operations.
2.03 The events at Three Mile Island have significantly changed both public and industry recognition
that a serious nuclear power plant accident is possible.
2.04 The industry is attempting to respond to thisnew reality.
2.05 Through the Institute for Nuclear PowerOperations and other means the industry should:
A. Continue to stress that nuclear power plants require numerous distinctive safety considerations
not present in other kinds of electricity generati ng plants.
B. Upgrade the standards and qualifications for
operators and other plant personnel. Increase
the frequency and sophistication of testing theability of plant personnel to respond to operational anomalies and malfunctions and perform otheraspects of their job.

Since local governments are legally creatures ofthe state, the state bears ultimate responsibility for
public health and safety. However, in the event ofan accident, local police, fire, health, and other authorities are responsible for immediate action toprotect the public.

C. Make certain that public authorities receive timely
warning of any accident with potential off-site
consequences, and keep them informed about
the condition of the plant.
D. Assure that adequate instrumentation is in place
to monitor radiation releases, on-site and off-site.
E. Cooperate with public authorities in the development of emergency plans and responses.
F. Conduct regular on-site and off-site drills of
emergency plans, in cooperation with public authorities.
G. Comply with the requirements of public agencies
with jurisdiction over civilian nuclear emergency
planning and response.

3.02 The jurisdictional boundaries of state and local governments pose extremely difficult problemsof coordinating planning and response. The NRC
Emergency Planning Zones suggest a ten mile radius, where practicable, for protection from airborne
radiation and a 50 mile radius for radiation ingested
through food.

planning
and2.06 Discussion-Emergency
response is only one limited aspect of an effective
safety management strategy. It is at least as important to prevent accidents as to be ready to respondto them. The civilian nuclear power industry has theprimary responsibility for the safe construction andoperation of nuclear power plants, and should
discharge this responsibility with full regard for public health and safety.
There was some difference of opinion within thepanel concerning the capability of the industry to
put into effect the substantial changes necessary toassure an acceptable level of safety. Increased
monitoring and oversight activities by NRC can provide information on which to judge whether the industry initiatives now being undertaken will meettheir objectives. When properly administered, agood oversight program can also act as an incentive
for industry to do its job well. The fact that utility insurance coverage is to be contingent upon compliance with INPO standards is a positive indicator of
the serious intent of industry to make INPO work.
The laxness of the past system for reviewing
emergency plans is illustrated by the fact that, as ofMay, 1979, only four nuclear facilities had been certified as conforming to the NRC's regulatory guidefor emergency planning issued in 1975. The factthat this guide is not a binding regulation and has
not been applied retroactively is suggestive of past
failure on the part of both industry and NRC to takeseriously the entire question of emergency planning.

3.03 At most plants, the zones include the jurisdictions of several local governments. An advisoryboard composed of representatives of thesegovernments as well as key private agencies is indispensable to prepare and coordinate the emergency plans of these governments. The chairman,
who should be appointed by the governor, must
play an important part in emergency drills andresponses.
3.04 Where the zone includes two or more states,
the chairman of such a board should be designatedby agreement between the two governors or, alternatively, be appointed by each governor on a rotati ng basis.
3.05 The feasibility of establishing an Emergency
Control Center near each site, with the capacity torespond to nuclear and other emergencies, should
be considered by each state and by the Federal
Emergency Management Agency. One model forsuch centers would be a mechanism combining
private and public sector representatives with thegreatest potential to contribute to successful
management of crises.
3.06 Discussion-The panel recognizes the needto improve state and local planning and response.
However, the panel does not believe that one
method or organizational form is appropriate for allstates and localities. Every state should develop
plans and an emergency response organization appropriate to its circumstances. To the fullest possible extent, planning for and responding to civilian
nuclear emergencies should be handled by thesame agencies and individuals who are responsible
for responding to other emergencies.
The panel's recommendations concerning stateand local government roles were developed in theState and Local Governments

3.01 Historically and constitutionally, state and local governments are responsible for public healthand safety within their boundaries. They are assisted by the federal government in areas of national
priority, such as epidemics, and in matters thatcross state lines.
1159

context of the findings of the National Governors
Association study entitled Comprehensive Emergency Management. That study underscores theneed for a substantial upgrading of the genericemergency management capabilities of state
governments as well as special capabilities for nuclear emergencies.
The Federal Government

4.01 The Nuclear Regulatory Commission is
responsible for regulating the design, construction,and operation of plants to protect public health andsafety. It is not responsible for planning for or
responding to the off-site effects of plant radiation
releases. It is responsible, with other federal agencies, for helping state and local governments to protect public health and safety in case of suchreleases.
4.02 The Commission may have the legal right toi ssue orders to the owners of a plant about how
they should operate a plant during emergencies.
The Commission should clarify its own emergency
plans to determine when and under what circumstances it should do so. The panel believes
that such orders should be issued only in thegravest of circumstances that pose a clear andpresent danger to public health and safety.
4.03 The Chairman of the Nuclear Regulatory
Commission should be given plenary power tospeak and act for NRC in an emergency. The
status of and resources available for emergency
planning and response throughout NRC, particularly
the Office of State Programs, should be
strengthened.
4.04 At present, the responsibilities of various
federal agencies for planning for and responding tocivilian nuclear emergencies are unclear. Most important, the respective roles of NRC, DOE, FEMA,
and EPA need to be clarified by the President andthe Congress.
4.05 Legislation should be enacted requiring thePresident, acting through the Federal Emergency
Management Agency, to develop a National Contingency Plan for nuclear emergency planning. This
plan should assign duties and responsibilities tofederal agencies, designate one authoritative coordinator for all federal activity at a site, and otherwise
define and clarify the planning and response process. Regional and national response teams composed of officials from designated state and federal
agencies should be formed and given training.

4.06 The
FederalEmergency
Management
Agency should by administrative action assume the"lead agency" powers and responsibilities for civilian
nuclear emergency planning and response now
nominally assigned to NRC. Its exact responsibilities should be defined in the National Contingency
Plan.
4.07 The federal government should establish a
grant program to assist state and local governments
in planning for and responding to civilian nuclear
emergencies. Eligibility should be conditioned upon
meeting designated grant requirements.
4.08 The NRC should require higher standards forplant operating personnel and should have an active
program for random testing of selected operator
personnel to insure that standards are being maintained.
4.09 Discussion-Nine months after Three Mile
Island there remains a disturbing confusion concerning the responsibilities of federal agencies in
responding to a nuclear emergency. A Federal
Register notice of December, 1975, stands as themost extensive and comprehensive effort to define
these responsibilities, but it is now outdated andprovides little effective guidance to help sort out therelative roles of the agencies. A year after theissuance of the Federal Register notice, the General
Services Administration issued a document entitled"Federal Response Plan for Peacetime Nuclear
Emergencies" (FRPPNE).
This document wasi ntended more as a guide for planning than an actual
plan, and its current status is uncertain at best.
Relying on legal doctrines of preemption, thefederal government has in effect prohibited stateand local governments from regulating plant emissions. On the other hand, it has not provided effective assistance or incentives to help state and local
governments carry out their responsibilities to
respond to accidents. The federal government
should take responsibility for this situation, which it
has in part created.
The Public

5.01 The primary purpose of civilian nuclear power
emergency planning and response is to protect thehealth and safety of people and the safety of property in the plant vicinity. People need to know thedangers to which they may be exposed, and the actions they can take to avoid or minimize them.
5.02 Plans that require public participation in suchactions as staying indoors, taking medicine, or eva1160

tic exercises for dealing with both nuclear and nonnuclear crises.

cuating should be developed to the extent feasible
with the participation or representation of the public.
It is unrealistic to expect people to implement plans
about which they are uninformed.

Footnotes for Part I

5.03 The public should be informed about nuclear
plant emergency plans and given an opportunity toparticipate in their preparation and revision by suchmeans as annual hearings.

'Panel member David Cohen states that the inclusion of this section on the Nuclear Power Industry at
the beginning of the report is inconsistent with the
purpose of this project, which was to examine alternatives for governmental action.
2
Panel member Richard P. Pollock states the following supplemental views on the NAPA/NRC Panelon Emergency Planning for Nuclear Incidents:
Reactor crisis management and emergency planning for radiological accidents do not lend themselves to simplistic solutions. It is a highly complicated topic, further clouded by conflicting politicaljurisdictions and splintered areas of responsibility.
Faced with these complexities, the National
Academy of Public Administration demonstrated
commendable proficiency, especially given the short
ti me frame NAPA was given to complete their assignment. Their efforts are the product of thoughtfulreflection and vigorous investigation.
Given these difficult circumstances, the panel
comments are in general a positive step forward,
signaling an end to the years of indifference paid tothis crucial topic by industry and regulators alike.
Given the diversity of the group, it is a fair consensus document.
someparticular
Nevertheless,
there
are
weaknesses which should be noted.
There is an unfortunate and undeserved degreeof deference towards the commercial nuclear industry in this report. The record of "past accomplishments" over the last 30 years is undocumented.
The claim that few radiological accidents havethreatened the public health and safety is unsubstantiated.
If there is any conclusion to be drawn about theatomic power industry it is quite the opposite. As
the Presidential Commission on the Accident atThree Mile Island noted, "To prevent nuclear accidents as serious as Three Mile Island, fundamental
changes will be necessary in the organization, procedures, and practices-and above all-in the attitudes of the Nuclear Regulatory Commission, and to
the extent that the institutions we investigated are
typical, of the nuclear industry."
The statement that few accidents havethreatened public health and safety, moreover, isfactually in error. In the 17 years since the firstcommercial reactor was ordered, the Atomic Energy
Commission and the Nuclear Regulatory Commission have docketed thousands of accidents involv-

5.04 Discussion-The panel's deliberations on this
topic were conducted in the light of the GAO report
entitled "Areas Around Nuclear Facilities Should Be
Better Prepared for Radiological Emergencies."
That report, issued only two days after the accident
at Three Mile Island, points up the great ignorance
on the part of the public living near nuclear plants
about emergency plans.
Emergency Plans

6.01 Because emergency planning often means
planning for events that never occur, it can become
artificial unless the plans are periodically exercised
and revised in the light of experience. Responsibilities for planning should be assigned to agencies andindividuals accustomed to preparing for andresponding to emergencies. Periodic drills and tests
should be conducted to assure that plans can work.
A "living system" as opposed to merely paper
planning should include the following features:• Drilled emergency on-site/off-site plans involving
•
•
•
•
•

local, state, federal officials and industry
representatives who should know each other andbe able to work together.
Pre-arranged stockpiles of specialized equipment, personnel rosters, and transportation.
Access to scientific/technical expertise.
Plans for providing accurate and timely information to the press and the public.
Logistical support for crisis managers and provision for rotation or replacement of personnel.
Continuous review and evaluation of the effectiveness of response mechanisms and recognition ofneed for adaptation to meet changing requirements.

6.02 The Governor of each state should exercise
responsibility for making certain that "living systems" exist.

6.03 Discussion-The panel recognizes that many
units of government and industry have done extensive planning for civilian nuclear emergencies. Moreresources are needed, and continuing efforts should
be made to improve these plans and conduct realis1161

i ng human error, component failure and design error. Significant accidents, such as the 1966 partial
meltdown of the Enrico Fermi I reactor forced local
officials to draw up contingency plans for the evacuation of Detroit. Reactor accidents of major significance also have occurred in Illinois, New Jersey,
Alabama, Connecticut, Colorado, Florida, Virginia,
and Minnesota.
Due to equipment failure or design error close to
one-third of all commercial reactors were shut down
i n 1979. It is not an enviable record of accomplishment. These flat "assertions" of a good record ofsafety are without corroboration. That they shouldbe published is an indication of a lack ofcomprehension by the panel of the nature of therisks.
But in any event, past safety is not the issue forthis panel. Preparedness for future accidents is thespirit and heart of this panel's concern. Emergency
planning will be the last line of defense when allplant safety systems fail. Responsible government
officials must develop a capability to protect the
public if there is a nuclear emergency in their region.
Evaluating federal, state, local and utility emergency
plans is the mandate of this panel. That is our mission.
On that note, it must be stated in the strongest
terms that the state of emergency planning is poor.
This conclusion is inescapable. Only four reactors
sites have been certified as conforming to NRC's
1975 regulatory guide for emergency planning. Only
thirteen states in the nation have received federal"concurrence" or approval for their state plans.
Operator training and testing for the complete spectrum of credible accidents is not required. Neither isthe annual testing of offsite emergency plans.
Since Three Mile Island, the industry has begun
to adopt some measures to attempt to upgrade their
low standards for performance. That too is noted in
the report. The industry has established a new institute in Atlanta. A Safety Center will be established in 1980. A flurry of media ads have beenpurchased to tell the public of these new efforts.
Is the industry responding to this "new reality?"This report suggests that it is. We contend, however, that it is premature to judge. Results, not plans,
are what regulators and policymakers must use tomeasure success or failure. It is therefore inappropriate for this panel to draw any conclusions
about the effectiveness about industry effortsefforts still are in the gestation period. For the
event which stirred the atomic power industry out of
its self-admitted lethargy was not self-policing officials, but an accident where operators and1162

machines repeatedly failed. How long this new industry "activism" prevails remains to be assessed.
There is also a suggestion that the industry's
new standards will be rather rigorous due to the factthat eligibility for entry into the industry institute will
be linked to a new insurance program.
This conclusion is unwarranted for the "insurance" being discussed is not liability insurance.
This is already secured by reactor owners throughthe federal Price-Anderson Act. A distinctive
feature of the Act is that companies are protectedby a Congressionally-imposed ceiling on liability.
The limitation is $560 million, less than 1/25th thedamages calculated by the NRC's Reactor Safety
Study in 1975 for a worse case accident. This insurance pool of $560 million is not conditional upon
participation in the new industrial standards program.
The "insurance" being offered is a secondary level of protection to cover the costs for purchasing
additional electricity if a nuclear power plant is down
for an extended period.
The insurance-standards link is weak. Moreover,it will be even weaker if the industry standards
themselves are low. Under those conditions, eligibili ty for this secondary type of insurance will be almost automatic. It is unfortunate that the panel conclusion report should draw inferences from the link.
I n particular, there are a number of quantifiable
steps which can be taken to upgrade the state of
emergency planning which are not included or
clearly stated in the panel's conclusion document.
These include:
1. As a part of doing business, utility companies
operating nuclear reactors should help local andstate governments finance radiological emergency planning and exercises. It is a recommendation urged by the NRC's Office of State Programs.

2. The Federal Emergency Management Agency
should preempt NRC on emergency planning.
FEMA should evaluate and certify plants andsites. Licensing of reactors should be contingent
upon FEMA approval of sites and plans.
3. Where FEMA determines a site to be unevacuable, measures should be adopted to remove thefacility from operation.
4. Emergency drills should include voluntary evacuation of the public in different sectors locatedaround plants. Regular notification of what is expected from the public during emergencies
should be sent out to all accidents within 50

miles from a reactor. Both the airborne pathway
and the ingestion pathway should be explained.
Dissemination of this information could be accomplished by inserts in the monthly electric bills,
public hearings or public service announcements.

1163

Nuclear power requires a certain degree of risks.
But the public, government officials and industry
representatives must confront those risks and takeprudent steps to cope with them. It is the only
responsible approach government can adopt.

APPENDIX 111.7

STATE AND FEDERAL EMERGENCYRESPONSE: AN AGENCY-BY-AGENCYACCOUNTI NTRODUCTION

sons, we are able to judge only the collective
Government performance of a particular emergency
response function, such as radiological monitoring,which we do in the main text. Therefore, the following pages should be considered as documentaryrather than analytical.
For purposes of this discussion, we have continued to rely on the basic categories of official
response functions that are used in the main text:planning, protective actions, radiological monitoring,
institutional communications, and technical support
for the plant. We refer the reader to the following
official documents, explained and examined in themain text, that pertain to the response effort:

This Appendix describes the efforts of eachState and Federal agency (except the NRC) that
played a substantial role in the emergency response
efforts. Each section first discusses the agency's
statutory and other authorities and responsibilities
and then describes how the agency became involved in the response. The sections conclude withdetails of the agency's response to the emergency
at TMI.
General conclusions about the adequacy of any
agency's response should not be drawn solely fromthe information provided in this Appendix. The official response effort comprised work by a large
number of agencies, each assigned varying but
often overlapping responsibilities. Many agencies
made extensive efforts during the accident at TMI;
not all can be fully detailed here. Furthermore,some information critical to assessment of a particular agency's performance might not have been obtained by the Special Inquiry Group. For these rea-

1. The Federal Response Plan for Peacetime Nuclear Emergencies (FRPPNE), Interim Guidance,
issued in 1977.
2. The Interagency Radiological Assistance Plan
(I RAP), as amended in 1975.
3. The Commonwealth of Pennsylvania Disaster
Operations Plan, revised in 1977.
1164

form of the Federal Response Plan for Peacetime
Nuclear Emergencies (FRPPNE). It intended that
FRPPNE would provide guidance for the development of response plans for handling serious, but notprobable, nuclear-related emergencies, and then integrate these plans with other existing responseplans to make a single document.
The stated purposes of FRPPNE were the followi ng:

4. The Pennsylvania Emergency Management Services Code of 1978.

SPECIFIC RESPONSE OF
FEDERAL AGENCIES (OTHER
THAN THE NRC) TO TMIAt the time of the Three Mile Island accident, sixFederal agencies, the Federal Preparedness Agency(FPA), Federal Disaster Assistance Administration(FDAA), Defense Civil Preparedness Agency( DCPA), Department of Energy (DOE), Environmental
Protection Agency (EPA), and Department of Health,
Education and Welfare (HEW) bore major responsibilities for responding to a peacetime nuclear accident. This part of Appendix 111.7 first deals withthese agencies and with the White House involvement. It then examines, in alphabetical order, theresponse of agencies that played lesser roles. Thispart of the Appendix also examines three organizations that are not Federal agencies but are of national scope and importance and therefore bear apublic imprint either in their charter or management:
the American Red Cross, the Civil Air Patrol, andConsolidated Rail Corporation.
Because of space limitations, the Appendix does
not treat other Federal agencies and nongovernment groups such as the Mennonite Relief
Service and various short-wave radio groups that
played a limited or standby role in the response effort. We here acknowledge the importance of theirservices.

1.

1. Provide policy and planning guidance for the
preparation of Federal and State operational
response plans for peacetime nuclear emergencies.
2. Facilitate a complete and coordinated Federal
planning effort that would cover all peacetime nuclear emergencies.
3. Provide the basis for compatibility between
Federal and State plans related to peacetime nuclear emergencies.
4. Identify responsibility for implementing and coordinating the efforts of Federal agencies respondi ng to peacetime nuclear emergencies.
Under FRPPNE, FPA undertook responsibility foroverall coordination of the civil emergency
preparedness planning effort designed by the
FRPPNE interim guidance. In carrying out this
responsibility with respect to peacetime nuclear
emergencies, FPA was to do the following:

1. Provide a continuous forum for the coordinationof Federal peacetime nuclear emergency planning activities, including making FPA personnel
available to facilitate those efforts.
2. Provide additional or revised policy and planningguidance whenever such action would serve a
useful purpose.
3. Review the guidance that leading planning agencies provide to support agencies.
4. Provide
assistanceinresolvingFederali nteragency or Federal-State problems wheneversuch action facilitates the fulfillment of responsibilities assigned to Federal agencies by this guidance.
5. Encourage States to produce plans related tothis guidance as part of their general State civil
emergency preparedness planning.
6. Coordinate visits of Federal agency representatives to States in connection with the development of peacetime nuclear emergency plans
under this guidance.
7. Ensure that Federal plans are mutually compatible and consistent, paying particular attention tomeasures designed to provide for an orderlytransition if a situation escalates from a lesser to

FEDERAL PREPAREDNESS AGENCY

Organization, Responsibilities, and Authorities

At the time of the Three Mile Island accident, theFederal Preparedness Agency (FPA), a part of theGeneral Services Administration, was charged withresponsibilities for the governmentwide civil emergency preparedness program. Its mandate included
coordination and development of national civil
preparedness policies and plans, fostering of Stateand local participation in preparedness programs,
and the performance of functions incident to theemergency mobilization of industrial resources addressed in the Defense Production Act of 1950.
(FPA and its functions have been integrated into the
newly established Federal Emergency Management
Agency (FEMA) as of July 15, 1979.)
I n April 1977, in accordance with its assigned
responsibilities and functions, FPA issued an interim1165

a more serious category of peacetime nuclear
emergency.
8. Determine the format of the compendium of plansthat would comprise the final version of FRPPNE
and the manner and timing of FRPPNE's promulgation.
Initiation of Involvement

FPA's regional office in Philadelphia first received
notification of the TMI incident from the NRC at approximately 9:45 a.m. on March 28. The informationi ndicated that a relatively serious release had occurred within the facility, but that most of the contamination had been contained within the powerplant. The regional office immediately relayed thisi nformation to the FPA national office in Washington.
At 10:00 a.m. the NRC Incident Response Center
called the FPA national office with the same information, and with further information that the temperature around the core of the reactor was slowly
declining-an indication that the problem was probably under control.
Description of Response

On March 28 and 29, the FPA national officemaintained frequent contact with the NRC Incident
Response Center in Bethesda, Md., for the latest information on the situation. The NRC also informed
FPA about the emergency response role played by
DOE and EPA. The FPA regional office in Philadelphia was in frequent contact with the Commonwealth of Pennsylvania's Emergency Management Agency (PEMA) to determine if additional
Federal assistance was required.
Following a report received from the NRC on themorning of March 29 that "the reactor [had been]stabilized since 9:00 p.m. on March 28," FPA
determined that no additional Federal assistance or
coordination of Federal efforts was required during
those 2 days. FPA was told that the only additional
release of radiological contaminants would be extremely low level, controlled releases made to
reduce pressure inside the containment facility.
On Friday, March 30, 1979, two factors resulted
in FPA's reassessment of the situation: First, thegrowing concern with the hydrogen bubble and thepotential for explosion led to FPA's conclusion thata serious problem still existed. Second, the reportedly "uncontrolled" release of radioactive gas on themorning of March 30 indicated that a serious levelof contamination outside the powerplant was still
possible. The FPA Region 3 acting director alerted
the regional staff of several Federal agencies to beprepared for a possible call for assistance from theState. He advised further that FPA might at any
ti me call to coordinate their activities.
At midmorning on March 30, FPA was requested
to attend a White House meeting to discuss Federal
agency involvement at TMI. At the meeting thatafternoon, FDAA was designated as the leadFederal agency in responding to the accident.
After that meeting, all FPA action was taken insupport of FDAA. During the weekend, FPA continued its coordinating role by organizing a meeting at
the request of Adamcik (FDAA) for regional personnel from the Department of Transportation (DOT),
Department of Agriculture (USDA), Department of
Defense (DoD), Postal Service (LISPS), and theVeterans' Administration (VA).
Beginning on Saturday, March 31, the FPA Region
3 acting director was in Harrisburg; the FPA Region
2 director arrived on April 1. At the request of
Governor Thornburgh, FPA took part in a Federal
evaluation of State evacuation plans. The two FPA
regional directors continued to provide support
throughout the week, until the possible need toevacuate areas around the powerplant had dimini shed.
2. FEDERAL DISASTER ASSISTANCEADMINISTRATION

Organization, Responsibilities, and Authorities

At the time of the TMI incident, FDAA was a partof the Department of Housing and Urban Development (HUD). The FDAA was responsible for direction, management, and coordination of the Federal
disaster assistance program activities delegated to
the HUD Secretary by the President. About 90% of
the disasters to which FDAA had responded before
TMI were floods; approximately 99% of its funds
were committed to flood relief and recovery. The
Administrator of FDAA directed regional and field office disaster assistance activities through 10 regional
directors; the regional director for the Pennsylvania
area was located in Philadelphia. As a result of a
July 1979 reorganization, FDAA is now part of
FEMA.
Under Executive Orders 11051, as amended, and11490, as amended, the Secretary of HUD was todevelop a comprehensive, coordinated Federal
operational plan for responding to emergencies arisi ng from a serious nuclear incident-one that could
reasonably be expected to result in severe property
damage or a large number of casualties, or that
could cause widespread contamination of people
and property.
To the extent that its comprehensive operational
response plan relies upon the Disaster Relief Act of1166

1974 for authority, FDAA is required to coordinate
the plan with the appropriate Federal departments
and agencies. In addition, the FDAA, in preparing
the response plan, is required to provide for liaisonand coordination with appropriate Federal departments and agencies providing technical assistance,
resources, and support. FDAA is also required tostress the need for coordinating the Federal assistance portion of the plan with State and local agencies engaged in comparable response activities involving peacetime nuclear emergencies.
The Disaster Relief Act of 1974 empowers the
President to declare a state of emergency or majordisaster, and thereby provides authority for FDAA's
emergency function. The formal declaration of adisaster also authorizes expenditure of Federal
funds under the Act and provides generally for
Federal disaster assistance. After the declaration,
the President appoints a Federal Coordinating Officer, who has coordinating authority sufficient toorganize the response to the disaster. The Act
authorizes FDAA to require any Federal agency toprovide whatever services, material, equipment, or
facilities are within its capability to provide. FDAA
can impose these requirements with or without
reimbursing the agencies involved.
Under the Act, FDAA is responsible for administering and coordinating the Federal disaster assistance program whenever a peacetime nuclear emergency results in a Presidential declaration of a majordisaster or emergency. Further, the FDAA develops
emergency response plans for carrying out its functions whenever any such declaration is made, if thei ncident constitutes a peacetime nuclear emergency.
TMI presented a unique situation for the FDAA.
The Governor did not request Federal assistanceunder the procedures provided in the Disaster Relief
Act of 1974 because, reportedly, he was concernedthat calling TMI-2 an "emergency" or "major disaster" would have had an adverse psychological effecton the populace. Thus the President could not declare a disaster under the 1974 Act, and FDAA had
no statutory authority either to require assistancefrom other Federal agencies or to expend funds.
But, since it was apparent that both technical andlogistical Federal assistance was needed, the WhiteHouse appointed Robert Adamcik, Director of
FDAA's Philadelphia office, and gave him the title,
Lead Federal Official, to take the place of the normally appointed Federal Coordinating Officer. The
White House also instructed FDAA to operate as
though an emergency had been declared. If there
should be any reluctance by a Federal agency toprovide assistance requested by the NRC or theState, FDAA was instructed to pass the matter tothe White House for resolution.
I nitiation of Involvement

At 11:00 a.m. on March 28, the NRC notified
FDAA of a radioactive discharge at TMI. FDAA took
li ttle action until March 30, when Adamcik was
designated Lead Federal Official and FDAA was assigned coordinating functions by the White House.
Adamcik arrived in Harrisburg at 11:00 p.m. on
March 30.
Description of Response

I n a March 30, 1979, memorandum from William
Wilcox, FDAA Administrator, Adamcik was formallynotified that Jack Watson, Assistant to the
President, had appointed Adamcik Lead Federal Official, with the task of coordinating all Federal activities related to the TMI accident. Adamcik was given
the general charter of performing as if he had been
designated Federal Coordinating Officer under aformal declaration of disaster, and had the following
specific assignments:
1.

Meet with the State Coordinating Officer andadvise him of his availability to assist as needed.
2. Meet with the President of Metropolitan Edison
Company to obtain a "general perspective of
attitudes and situation as viewed by the company."
3. Establish a Federal Congressional Liaison Office.
4. Cooperate with the State in establishing a rumor control center.
5. Establish onsite liaison with Harold Denton of
the NRC.
6. Convene a meeting of Federal employees
responding to the accident and advise them ofhis presence.
7. Meet with Federal officials assisting the State.
8. Provide at least daily reports to Jack Watson.
9. Coordinate with John McConnell of the DCPA,
who was monitoring local evacuation capabilities.
10. Discuss with State officials the preparation ofan unsigned emergency request to the
President for immediate use should the situation worsen.
At about the same time, FDAA's National Operations Center in Washington, D.C., became involved
i n TMI and, throughout the next several days, committed almost all its resources to TMI support.

1167

Upon his arrival in Harrisburg, Adamcik contacted
Oran Henderson, Director of PEMA, who by law is
the State Coordinating Officer, and who served as
Adamcik's primary State contact throughout the incident.
FDAA also served the State by making arrangements to obtain equipment and personnel that theState had determined to be necessary for an evacuation, but which were not available within the State.
On April 2, PEMA asked FDAA to locate 440 ambul ances, 1 fixed-wing aircraft, 40 incubators for neonatal patients, 183 200 blankets, 183 200 cots, 35
doctors, and 200 nurses. By April 3, FDAA, withassistance from the American Red Cross, had identified sources for most of these needs, although
FDAA daily reports to the White House indicatedthat problems were encountered in obtaining sufficient numbers of blankets and cots.
FDAA provided technical advice and assistanceto the State in setting up a Rumor Control Center,
which opened April 4.
At the Federal level, Adamcik maintained liaison
with the NRC technical support staff on site throughBoyce Grier, Director of the NRC's Region I, whom
Denton, the lead NRC official on site, had designated as FDAA contact. Adamcik also attended thedaily briefing that Denton gave the Governor. Soon
after his arrival, Adamcik established liaison withJohn McConnell of the DCPA, who had been sent to
TMI to assist in the development of evacuationplans. FDAA representatives were also stationed at
the NRC Operations Center in Bethesda.
Throughout the incident, FDAA served as theprincipal point of contact for the NRC, the DCPA,
and other Federal agencies needing to obtain materials or services in support of Federal operations
at TMI. While many of the requests for assistancecame through Adamcik's office in Harrisburg, many
also were made directly to FDAA's National Operations Center in Washington, D.C. FDAA had no
responsibility for and took no part in coordinating
the Federal radiological monitoring efforts at TMI.
On Sunday, April 1, Adamcik convened the 25 to
30 Federal agencies and private relief organizations
on site at that time for his first Federal agency coordination meeting in Harrisburg. State officials also
attended. Daily coordination meetings with all
Federal agencies were held right up through the following Friday to discuss general plans and to bringthe agencies up to date on recent events and thesituation at the reactor. Smaller meetings withrepresentatives from one or a few Federal agencies
or with State officials were held as the need arose.
Adamcik did not establish contact with officials of
Met Ed because the NRC had already established a1168

relationship with the company. Adamcik did not beli eve that he should interfere with technical aspectsof the accident.
Because of their number, Adamcik chose not toconvene a meeting of all Federal employees on site,
but rather met with the Federal agency heads andadvised them to inform their staffs of his presence
and mission.
FDAA submitted to the White House 10 daily reports on Federal activities on site, beginning March
30 and ending April 11. No reports were preparedon Saturday and Sunday, April 7 and 8, or on Tuesday April 10.
FDAA's role at TMI has essentially ended. On
April 13, the White House designated various other
Federal agencies as lead agencies for specific longterm recovery tasks.
3.

DEFENSE CIVIL PREPAREDNESS AGENCY

Organization, Responsibilities, and Authorities

At the time of the TMI-2 accident, DCPA was aseparate agency under DoD and was headquarteredi n the Pentagon. Eight DCPA regional centers reported to the Director of the Agency. The regional
center responsible for the area around the TMI nuclear plant was the Region Two Center, locatednear Olney, Md. DCPA and its functions were assimilated by FEMA in accordance with Executive
Order 12148, effective July 15, 1979.
DCPA had been responsible primarily fordeveloping and coordinating Federal, State, and local preparedness for a nuclear attack on the UnitedStates. In addition to this legislated mission, the civil
defense "dual use" doctrine allows military
preparedness resources to be used for nonmilitary
preparedness functions. Under this doctrine, DCPA
has provided extensive support for nonmilitary
disaster preparedness planning and operations.
Through use of matching funds and other resources
provided to States (and indirectly to counties andcommunities) and through its training programs,
DCPA has had a major influence on disaster
preparedness planning throughout the UnitedStates. At the time of the TMI-2 accident, thePennsylvania Emergency Management Agency( PEMA) had 47 full-time employees and 6 part-time
employees whose salary, travel, and administrative
expenses were shared equally by the Commonwealth and DCPA. City and county emergency
preparedness agencies in Pennsylvania had a totalof 92 full-time and 26 part-time employees whosesalaries and expenses were also shared equally by
DCPA.

Through its regional centers, DCPA maintained
routine contacts with State Emergency Operations
Centers, and it normally served as the principal
Federal communications link with local and State
personnel actually conducting disaster operations(as opposed to post-disaster recovery and assistance, for which FDAA and other agencies became
i nvolved).
DCPA had signed the Interagency Radiological
Assistance Plan (IRAP), which charged DCPA with 1)
performing those civil defense and disaster warning
functions delegated to the Secretary of Defense,and 2) providing natural disaster preparedness planning assistance to State and local governments.
DCPA also had responsibilities assigned under
the provisions of FRPPNE, issued as interim guidance in April 1977. Under those provisions, asapplicable to fixed facility nuclear accidents, DCPA
was responsible for the following:

1. I ssuing guidance on the use of civil defense
resources, including warning, communications,training, and radiological defense emergency
response systems) at all levels of government;
2. Assisting the NRC in providing State and local
governments with training, onsite assistance, andother assistance in preparing and exercisingpeacetime
nuclearemergency
operational
response plans for fixed nuclear facilities;
3. Warning the population, through State and local
governments, if feasible, of the expected impact
area in the event of an impending nuclear incident; and4. Informing the public of protective measures to betaken to mitigate the effects of a major radiological contamination.
Initiation of Involvement

The DCPA Region Two Center near Olney, Md.,
was notified of the TMI-2 accident by PEMA at 8:45
a.m. on March 28. Although there were no prearranged plans for PEMA to notify DCPA in the eventof such an accident, notification was in accordancewith the actions PEMA would be expected to take inthe event of any sizeable emergency. The Region
Two Center notified DCPA headquarters of the accident at 9:00 a.m.
Description of Response

At approximately 10:00 a.m. the DCPA RegionalField Officer for Pennsylvania, who was participating
i n a preparedness conference at the PEMA Central
Area Headquarters in Selinsgrove, Pa., was directed
to go to the PEMA Emergency Operations Center in
1169

Harrisburg to monitor the emergency and to assist
PEMA. A Disaster Operations Center was activatedat the DCPA Region Two office. No other action
was taken during the first 2 days except for
responding to requests for information regarding theaccident and maintaining contact with PEMA andthe NRC. Based upon the information they obtained, DCPA inferred that the situation at the plant
was under control and that no further action would
be required.
Following the radiation release on Friday, March
30, DCPA personnel attended the afternoon meetingat the White House to discuss Federal agency
response. At the meeting, John McConnell, DCPA
Assistant Director for Plans and Operations, wasdesignated Federal advisor to the State for purposes of evacuation planning. McConnell arrived at
the PEMA Emergency Operations Center (EOC) in
Harrisburg at about 5:00 p.m. Also on Friday, asecond Region Two Field Officer was sent to Harrisburg to permit 24-hour coverage of the PEMA
emergency center. Eight staff members from Region Two were sent to the principal risk counties tosupport the county planning efforts, two each to
Dauphin, York, Lancaster, and Cumberland Counties. Two U.S. Army Communications Commandpersonnel with high frequency radio sets weredispatched to York and Lancaster Counties, where
they established a radio net linking the counties, thePEMA emergency center, and the Olney Regional
Center.
Over the weekend of March 31 to April 1, the
DCPA personnel assigned to the risk counties functioned as members of the county planning teams,
and in some cases served to actually draft thecounty evacuation plans after county and State authorities had put together the basic concepts of theevacuation. McConnell, operating out of the PEMA
EOC, visited the risk counties to provide supervision, and as senior DCPA representative, beginning
April 1, he attended the daily Federal agency coordination meetings arranged by Robert Adamcik of the
FDAA.
On Monday, April 2, four additional radio operators with equipment were sent to Dauphin, Cumberland, Lebanon, and Perry Counties, allowing for establishment of an independent radio net linking thesix counties at risk, the PEMA emergency center,and the Region Two Center. Most of the net was
operational by late Tuesday, April 3, in spite ofsome delays caused by damage to equipment whilein transit and a shortage of spare parts.
Although the concept was good, actual performance of the radio net was deficient. Because thesets were designed to operate at the low end of thehigh frequency band (4 780 KHz), the signal-tonoise ratio was low, and operation of the sets interfered with a computer near the PEMA EOC. The radios were awkward to use since they consisted ofmore than one unit, and were easily damaged in
shipment.
On April 2, DCPA also furnished 6 000 low range
personnel dosimeters (CDV-138) in response to
PEMA requests. These were issued by PEMA toFederal, State and local personnel operating in potentially hazardous areas. The State already possessed CDV-700 high range dosimeters, but it wasdifficult to obtain accurate measurements with themi n the low radiation fields encountered.
On April 2 two additional DCPA health physicist
and radiological defense officers joined the DCPA
staff at the PEMA emergency center, and 19 additional DCPA staff personnel were dispatched to thehost counties to assist them in planning for evacuees. These personnel had arrived on site by Tuesday, April 3.
A team of three DCPA personnel assisted in radiological monitoring using a portable scintillation
counter.
During the period following the accident a total of
about 50 DCPA personnel were involved in supportof PEMA and the county emergency management
agencies. Beginning on April 6 and extending toApril 8, the personnel assisting the host counties
completed their work and were released. On April
7, Frank Vogel, Deputy Assistant Director forOperations, reported to the State EOC as relief for
McConnell. During the period from April 10 to 13,
the balance of the DCPA staff returned home.
4. DEPARTMENT OF ENERGY
Organization, Responsibilities, and Authorities

In matters involving nuclear applications of either
a military or nonmilitary nature, DOE is the successor of the Atomic Energy Commission and has inherited its technology development and support
responsibilities. It is party to written agreementswith DoD, the Federal Bureau of Investigation, andthe NRC that cover shared responsibilities. With adozen other Federal agencies, including both the
DoD and the NRC, DOE is a signatory of the IRAP.
Application of these agreements in an emergency
response is not, however, without ambiguity. DOE's
agreement with the NRC, for example, provides for
DOE support when requested by the NRC in connection with an emergency at a licensed nuclear facili ty. IRAP, on the other hand, is unclear about how
it i s to be invoked, but indicates that DOE is theagency "responsible for directing the administration,
implementation, and application of the provisions of
the IRAP." Appendix Figure 111-10 provides a partialorganization chart for DOE. The radiological monitoring services supplied through the Operations Offices, which administratively report to the Under
Secretary, involved the Radiological Assistance Program (RAP) teams, which report to the Operational
and Environmental Safety Division under the Assistant Secretary for Environment.
The organization of the radiological assistanceefforts, which were more complex than other DOE
support efforts, is indicated in Appendix Figure III-11.
Coordination was provided by onsite representatives of DOE's Operational and Environmental Safety Division. RAP teams from DOE's Region 1 officeprovided direct support to the Commonwealth ofPennsylvania. Three Regional Coordinating Offices
and the Nevada Operations Office furnished support
for the NRC. Of course, all of the information obtained by DOE was available to all interested persons.
The TMI accident did not involve significant
offsite radiological contamination. In an accident at
a fixed nuclear facility that did involve such contamination, DOE and its contractors would have participated in the efforts to assess and mitigate the concomitant hazards.
I nitiation of Involvement

The DOE involvement began at 7:10 a.m. on
March 28 when Mr. Bensel, at TMI, contacted
Brookhaven National Laboratory (BNL) security toalert the RAP team to the incident. Mr. Greenhouseof BNL contacted TMI to determine the plant status
while the RAP team took measures to get a Coast
Guard helicopter put on standby. At about 8:45
a.m. the Brookhaven area office manager called the
DOE Emergency Operations Center in Germantown,
Md., to transmit this information. At 8:50 a.m. the
NRC Region I called the Brookhaven area office todetermine the RAP team status. Neither the utility
nor the NRC requested assistance at that time.
The DOE Emergency Operations Center contacted the NRC Incident Response Center at about 8:55
a.m. to confirm the general emergency condition at
TMI. No immediate assistance was requested.
At about 10:00 a.m. the Aerial Measuring
SearchTeam
System/Nuclear
Emergency(AMS/NEST) stationed at Andrews Air Force Basewas placed on standby alert, and at about 11:00 a.m.
a request was received from the NRC to have the
AMS/NEST moved to the Capital City Airport at
New Cumberland, Pa., to await instructions.
1170

APP. FIGURE III-10. DOE Organization Chart (Partial)

APP. FIGURE III-11. DOE Radiological Monitoring/Field Organizations

1172

Meanwhile, the Region I RAP team was contacti ng the NRC Headquarters Incident Response
Center, the NRC Region I Incident Response Center,and the Bureau of Radiation Protection (BRP), ofPennsylvania's
DepartmentofEnvironmental
Resources, in a continuing attempt to obtain a request to move. At 11:18 a.m. that request was obtained from BRP.
The AMS/NEST unit arrived at the Capital City
Airport at 1:30 p.m. on Wednesday and establishedan operations center in the airport manager's office.
The AMS/NEST equipment arrived later that afternoon, so the team could make aerial measurementsof radiation that same day. The RAP team, which
had expected to land directly at Harrisburg, had toland instead at the Capital City Airport because of
the size of its helicopter, arriving at about 2:30 p.m.
The team was driven into Harrisburg by State personnel. They then established their operational
center with the BRP, under whose direction they
were working. They had begun monitoring at the
airport while waiting for transportation to Harrisburg.
Late Wednesday afternoon the Emergency Action Coordinating Team at DOE Headquarters decided that the presence of two independent teams
working in support of two different organizations required onsite coordination by someone from DOE
Headquarters. Mr. Patterson was designated thesenior DOE representative. He arrived at the Capital City Airport at a little after 11:00 p.m.
By midnight on Wednesday, DOE had established the basic structure of its radiological support
effort. An airborne measurement capability was inplace and operational. Surface measurement teams
were in the field taking environmental samples andradiation measurements. An administrative structure had been established for the coordination of
DOE efforts, and communication channels had been
established with the NRC, the Pennsylvania BRP,
and DOE Headquarters.
During the second day of the incident, March 29,
1979, there were only modest changes in DOE involvement. A second AMS/NEST unit arrived fromLas Vegas at an early hour. Another RAP teamfrom BNL arrived at about 2:00 a.m. Dickerson, of
Lawrence Livermore Laboratory, was requested tocome to the DOE Command Post at the Capital City
Airport. Since Dickerson was in Chicago at theti me, he was able to get to Harrisburg quickly and to
begin providing local input to the AtmosphericRelease Advisory Capability (ARAC) at Lawrence
Livermore
Laboratory.
The laboratory uses
meteorological, topological, and effluent data to
predict the temporal and spatial distributions of airborne effluents. Enough telephones were installed
1173

in the State hangar at the airport to transfer theCommand Post from the manager's office to the
hangar, where it remained for the duration of theemergency response period. The BNL RAP teams,
which had been on continuous duty since their arrival, were replaced by Pittsburgh Naval Reactors
teams. Finally, Joe Deal of DOE's Operational andEnvironmental Safety Division was sent to the Command Post to relieve Patterson as senior DOE
representative.
On the third day, Friday, March 30, the rapid escalation of general concern was directly reflected in
the expansion of the DOE efforts in the radiologicalarea. It led also to the initiation of significant DOE
efforts in the area of plant support.
The Region I RAP teams, which had been functioning on a short term basis, were placed in a longterm operational mode. Brookhaven, Bettis, andKnolls Laboratories personnel were maintained in
the area concurrently and used on a shift basis sothat the RAP teams could continue to function effectively for an extended period. The Environmental
Measurements Laboratory also participated in theterrestrial measurements effort, providing their initial
data on April 2, 1979.
On Friday, March 30, at the request of the NRC,
DOE dispatched RAP teams from Oak Ridge, Argonne, and Mound Laboratories (in Tennessee, Illinois, and Dayton, Ohio, respectively) to support the
NRC's radiological monitoring efforts.
The AMS/NESTs, accustomed to longer term
operations, did not require additional personnel.
They did, however, require extra equipment andpersonnel as a result of engine trouble with the H500 helicopter from which they conducted theirmonitoring operations. Two AMS/NEST communications pods and support personnel came from Las
Vegas to facilitate monitoring communications offsite and to improve DOE Command Post communications with the State and the NRC.
The increase in offsite radiation measurement
made more effective coordination necessary. At
DOE's behest, the NRC and BRP representatives
met with the DOE representatives for a coordination
meeting. The meeting took place at the Capital City
Airport
at
5:00
p.m.,
March
30,
1979.
(Pennsylvania's BRP had requested that DOE takethe lead in the monitoring efforts.) That meeting,which was also attended by representatives of otheragencies, established the pattern for the remainderof the emergency response period. Each afternoon
after March 30, all of the organizations involved in
offsite monitoring met in the airport hangar topresent the data accumulated during the day, to discuss its significance, and to plan the next day's ef-

fort. At the request of the BRP, the DOE accepted
the responsibility for consolidation and analysis ofradiological data from all sources. The information,
which was developed at the request of the Commonwealth of Pennsylvania, was made available toall interested parties.
DOE's initial response on March 28, 1979, wasmade by 18 people in the TMI environs. This leveli ncreased almost linearly with time until Sunday,
April 1, at which time the number of DOE and DOEcontractor personnel in the area exceeded 100.
The involvement remained high through April 6. It
then decreased to about 50 for the last week of theemergency response period, through April 15.
Description of Response
Radiological Monitoring and Analysis

The AMS/NEST units used helicopters to locate,radially track, and define both the azimuthal andvertical extent of the effluent plume from the plant.
They used the sodium iodide scintillation detector
array, which they employ in background survey
measurements, as well as hand-held survey instruments, which were used when the sodium iodide
detectors became overloaded in the effluent plume.
They also obtained air samples in the plume andmeasured the energy spectrum of the gamma rays
to identify the radioisotopes present.
During the first few days, several flights weremade each day, but these did not necessarily
correspond to intervals of greatest venting from theplant. By March 31, an effort was being made toschedule a flight every 3 hours and to make special
flights when releases from the plant were expected.
These flights were facilitiated by information provided to the AMS/NEST units by the AtmosphericRelease Advisory Capability (ARAC). ARAC's prediction of plume direction, altitude, and dispersion
checked well with flight observations and expedited
locating and tracking the plume.
The data obtained with automated survey equipment was recorded on tape for analyses performed
in a van at the airport after the flight. The survey instrument readings were written down during theflight and turned in to the coordinator in the Control
Center. After the AMS/NEST communications gear
became available, direct radio communications with
the Command Post were possible, so that somedata, particularly unexpected data, was communicated by radio to avoid the normal time delay.
When the data became available to the AMS/NEST
coordinator in the Command Center, it was telephoned to the NRC and to DOE Headquarters, anda copy was given to the RAP team coordinator in
the Command Center.
DOE's Region I RAP team was operating at therequest of the Commonwealth of Pennsylvania in
support of the Commonwealth's offsite radiation
monitoring efforts. The team measured ambient radiation levels, took samples of air, vegetation, soil,
and water, and analyzed the samples to determine
both the type and quantity of radioactive material
they contained.
The BNL team that arrived on March 28 brought
and later used an air sampler containing a silveri mpregnated gel, a device developed at Brookhavento serve as a specific absorber for iodine. It was
not subject to the interference which led to early erroneous reports of iodine activity, interference
caused by xenon absorption, a usual occurrence
when using ordinary activated charcoal filters.
The team from Bettis brought a lithium-drifted
germanium (GeLi) spectrometer whose resolution
facilitated identification of radioisotopes. The Environmental Measurement Laboratory van at the airport was also equipped with high resolution spectrometers. Taken all together, a substantial laboratory analysis capability to analyze the large numberof samples collected each day was established at
the airport.
All of the data available at the Command Post
was communicated to the BRP office, where it wasposted on large maps to provide a visual perspective. During the first 2 days of the accident, when
the RAP teams were headquartered at the BRP offices, the RAP team data were analyzed and assembled there, and telephones were used to collectdata from other sources. After the RAP teams were
shifted to the airport to provide additional space at
BRP and to achieve better coordination with other
DOE radiation measurement efforts, other DOE personnel had to be assigned to BRP offices on around-the-clock basis to maintain the same level ofcoordination achieved earlier.
The RAP teams supporting the NRC worked outof a trailer park near the site. The area they
covered was closer to the plant and lay principally
along the roads paralleling the east and west banksof the Susquehanna River. They appeared to haveknowledge of plant operations and were more likely
than the BRP-connected teams to be out and looki ng for activity during a release. These teams, ofcourse, were not requested until March 30, and sowere not present during the more confusing earlydays.
The team from Mound Laboratory was assigned
to support HEW's Bureau of Radiological Health indistributing dosimeters out to 20 miles from the1174

plant. Within the Command Center, information obtained by all of the organizations involved in the radiation monitoring effort was continuously collected,
correlated, and displayed. A single display technique was commonly used to facilitate comparisonof many types of data, including "instantaneous"rate data, cumulative doses at given positions, andpopulation exposure estimates. This display technique was to present the data as an overlay on amap of the area so that the spatial relationships
among the data in a given set or among sets of data
could be more readily appreciated.
Also, the Director of the Human Health and Assessments Division of DOE spent the first weekendof the emergency in Harrisburg consulting withhealth officials of the Commonwealth of Pennsylvania and their advisors on the potential biologicalimpact of radiation releases from TMI.
Atmospheric Release Advisory Capability

DOE's ARAC at Livermore Laboratory was definitely an asset during this incident. After data began
to be transmitted automatically from the TMI
meteorological tower to Livermore, the AMS/NEST
unit reported that the ARAC predictions of plumecharacteristics corresponded very well with theirobservations and greatly simplified the task of locati ng and tracking the plume. On the other hand, for
the NRC, whose primary concern was with plume
behavior close to the plant, the mesh employed in
the ARAC analyses was too coarse.
Prospective users of ARAC would prefer that thesystem be modified from the presently required uniform mesh to a variable mesh, so that better definition close to the source could be obtained without
requiring either excessive computation or output.
There were several potential users, and getting
the output as rapidly as possible was urgent. The
sequential transmission to the various users was
slow; simultaneous transmission of output could significantly increase the system's value and acceptance.
Technical Support for the Plant

One of the first technical support efforts undertaken was the analysis of a primary coolant sample
from the plant done at Bettis Laboratory, near Pittsburgh, Pa. Additional samples of coolant water aswell as samples of containment atmosphere andwaste gas storage tank contents were also
analyzed at Bettis. Coolant sample analyses werealso made at the Savannah River Laboratory, Oak
Ridge National Laboratory, and the Idaho National
Engineering Laboratory (INEL).
1175

The mobile manipulator "Herman" and a team ofoperators were sent to TMI from Oak Ridge to obtain primary coolant samples. "Herman" was however never used, because of concerns about its reliability.
When the NRC put out a call for lead bricks toshield a recombiner at the plant, DOE sources aswell as other Federal agencies responded. Eighttons of lead bricks were supplied by Bettis; 43 tons
by Brookhaven.
The DOE also provided support to the utility
through the NRC. This support included public relations personnel from Headquarters and from Oak
Ridge; noise analysis, instrumentation capability, anda photographer from Oak Ridge; and technical experts from INEL. They arranged for Mr. Dietz of theNaval Research Laboratory to perform iodine"bleedoff" tests on samples of charcoal from filters
at TMI, using a method developed under DOE sponsorship.
Many DOE laboratories at which safety research
programs are supported by the NRC took part in investigations and analyses related to TMI plantstatus. Supplementary supplied air respiratory
equipment for use inside the plant was obtained
from Savannah River, and two air distribution manifolds were provided through the Richland Operations Office.
5. ENVIRONMENTAL PROTECTION AGENCY
EPA has responsibility for maintenance and improvement of air and water quality, including the establishment of standards for radioactive substances
as well as many other contaminants. To meet its
responsibilities, the agency:

1. Establishes Protective Action Guides, or PAGs
(projected radiation doses that might result fromradiation incidents at fixed nuclear facilities or in
the transportation of radioactive materials), incoordination with appropriate Federal agencies;
2. Recommends appropriate protective actions thatcan be taken by government authorities to mitigate the hazards of a radiation incident at a fixed
nuclear facility or from an incident involving transportation of radioactive materials;
3. Establishes emergency radiation detection andmeasurement systems guidelines in cooperation
with the NRC;
4. Develops guidelines for the disposal of solid
wastes and other debris, whether radioactive or
nonradioactive, which might contaminate the environment;5. Assists the responsible agency at the scene of
the incident by providing monitoring teams tomeasure environmental radiation and to evaluate
the extent of the contamination; and6. Ensures that adequate potable water is available
for public use.
I n normal operation, radiation monitoring is performed by two offices of the Agency. The Office ofRadiological Protection, under the Assistant Administrator for Air and Waste Management, maintains air sampling stations around the country andoperates the Eastern Environmental Radiation Facility in Montgomery, Ala. The Montgomery facility, in
addition to inhouse analytical capability, has amobile analysis laboratory which is available for use
throughout the Eastern United States. The Office ofMonitoring and Technical Support, under the Assistant Administrator for Research and Development,
maintains an airborne and terrestrial monitoringteam that provides offsite monitoring for the Nevada
test site.
EPA had a direct interest in the TMI accident because of its environmental responsibilities. It had
authority by legislation and regulation to monitor theenvironment whenever necessary.
I nitiation of Involvement

EPA received notification of the TMI accident
from the NRC at 9:05 a.m. on March 28, 1979. The
Agency activated its radiation alert office in Washi ngton, D.C., and placed its air sampling stations in
Wilmington, Del., Harrisburg, Pa., and Washington,
D.C., on a daily collection schedule. The next day,March 29, the sampling station in New York City
was also placed on a daily schedule. (Normally, asample is accumulated for an entire week before
being measured.) EPA also volunteered assistanceto Pennsylvania and was asked to remain on standby.
On Friday morning, March 30, the decision wasmade to undertake a comprehensive environmental
monitoring program in the TMI area. Douglas Costle, EPA Administrator, requested Stephen Gage, his
Assistant Administrator for Research and Development, to establish that program.
The EPA Environmental Monitoring Systems Laboratory in Las Vegas was requested to develop andto implement the necessary monitoring program.
Equipment and staff were on the way to Harrisburg
by a variety of routes during the afternoon of March
30, arriving in Harrisburg on Saturday afternoon,
March 31. By the end of the day, EPA had set up
equipment for sample analysis in the facilities of thePennsylvania Department of Health. An EPA control

center was located with the DOE team at the Capital City Airport.
On Friday, March 30, EPA began sampling waterfrom the Susquehanna River and the Chesapeake
Bay at its Annapolis Field Station. Aerial photographs of the area within 7 miles of the TMI plant
were obtained, and identification of dairy farms anddrinking water sources in the area was undertaken
by EPA's Warrenton Laboratory in Warrenton, Va.
The mobile analysis laboratory from Montgomery,
Ala., was alerted, and proceeded to Hagerstown,
Md.
The EPA response force from Las Vegas initiallyconsisted of 17 people and was increased to 21
several days later. The peak EPA involvement in
the TMI area was a total of 31, including representatives of EPA's Region III Office in Philadelphia.
At the completion of the emergency response
phase, EPA's role shifted to coordination of all radiation monitoring during the recovery phase.
Description of Response

The monitoring program that EPA conductedaround the TMI plant consisted of air sampling, continuous gamma radiation monitoring, water sampling,
dosimetry, milk sampling, and noble gas sampling.
Air Sampling

Sampling stations were established as follows:

1. A ring of 12 stations between 2.5 and 3.5 miles
from the reactor with an azimuthal spacing thatvaried from 15 to 45°.
2. A second ring of 10 stations between 4 and 7
miles from the reactor.
3. Nine stations at populated locations 7 miles ormore from the plant.

Each station contained an air sampler with an approximate capacity of 10 cubic feet per minute andhaving a fiberglass prefilter to collect particulate material and an activated charcoal cartridge to collecti odine. A delay in receiving filters and cartridges
postponed the activation of the air samplers. On
April 1 six samplers were activated in the inner ring,four in the second ring, and one beyond 7 miles.
On April 2, five more samplers in the inner ring,
five in the second ring, and four beyond 7 miles
were activated. The final sampler in each of therings and the remaining four samplers beyond 7
miles were activated on April 3. Filters and cartridges were changed daily and were analyzed by
gamma spectroscopy using the EPA's lithium-driftea
germanium (GeLi) detector in its analysis laboratory
at the Department of Health. Some samples werealso sent to Las Vegas for analysis.

1176

Continuous Gamma Radiation Monitoring

A gamma rate recorder consisting of a pressuri zed proportional counter with a strip chart recorder
was installed at each of the sampling stations, except for one station in the inner ring and one
beyond 7 miles. Recorders were also located at
two residences in Goldsboro and at one in PleasantGrove. The schedule for activation of the gammaray monitors is summarized in the table below.
NUMBER OF GAMMA-RAY MONITORSACTIVATED BY DATE

Location

I nner Ring
Second Ring
Beyond 7 Miles
Special Homes

3/31/79 4/11/79 4/2/79 4/3/79 4/4/79

Total

1
5
3

9

6
2
1
3

12

3
1
1

2
2

5

4

1

too high to detect the maximum concentrations acceptable for continuous consumption under EPA criteria, all samples were sent for analysis to theinEastern
Environmental
Radiation
Facility
Montgomery, Ala., where detection limits for 1311
were targeted at 15 pCi/I. Composite samples, accumulated over 24 hours, were collected from major
public drinking water supplies and were sent to theEnvironmental Monitoring Systems Laboratory in
Las Vegas for analysis.
Daily sampling of liquid effluents from TMI at theirpoint of discharge was also instituted. Samples
were collected by DER and analyzed by EPA in Harrisburg.
Dosimetry

1
2

These instruments had been calibrated for 137Cs(662 kiloelectron volt (keV) gamma rays). Because
the primary radioactive
component of the plant133
Xe, which produces low energy
releases was
gamma rays (81 keV), recalibration of that equipment
was required. Recalibration, which was performedby EG&G Company in Santa Barbara, Calif., and by
the National Bureau of Standards, showed that thedose rates were less than the original instrument
calibration had indicated.
The strip charts were collected daily, visually
examined, and manually integrated when an indication above background levels was noted. A value of
0.1 mR was used as the minimum practical reportable net exposure.
Water Sampling

After the arrival of the EPA team from Las Vegas,
the Susquehanna River sampling program initiatedby the Annapolis Laboratory was modified to better
complement the efforts of the Pennsylvania Department of Environmental Resources (DER). Four sampling stations were established at the Columbia
bridge location on the river. River water samples
were analyzed
in Harrisburg, where the detection1311
li mit for
was approximately 70 picocuries perliter (pCi/I).
In conjunction with the State DER, EPA
developed a program for sampling drinking water.
Over 100 sources of drinking water were identified
within 20 miles of TMI. Of these, 21 were surface
water supplies and thus were identified as priority
sampling sites. Samples from these priority sourceswere gamma-scanned in Harrisburg for grosscon1311
tamination. Because the detection limit for
was
1177

Thermoluminescent dosimeters (TLDs) were also
placed at the sampling stations. Three badges,
each containing two dysprosium activated calcium
fluoride chips were located at each station. In addition, approximately 50 TLDs were issued on a
voluntary basis to residents in the vicinity of thesampling stations.
Milk Sampling

Using photointerpretation techniques, 105 dairies
within 7 miles of the TMI-2 reactor and 465 dairies
within 25 miles of the reactor were identified. Afterevaluating the milk sampling programs of the Commonwealth of Pennsylvania, the FDA, and Met Ed,
EPA initiated a separate milk sampling program on
April 5, selecting nine dairy farms for daily sampling.
The EPA milk sampling program was undertaken tocomplement efforts of the other organizations alreadyactively sampling milk. The minimum amount1311
ofdetectable in these milk samples was 20
pCi/I.
Noble Gas SamplingThree stations were established for routine radioactive noble gas sampling. Compressed air samples of at least two-thirds of a cubic meter werecollected over a 2- to 3-day period. Samples wereanalyzed in the EPA laboratory at Harrisburg for133
Xe and 85Kr by a cryogenic procedure. Separation of the gases depends upon differences in theirvolatilization temperatures; quantity is determined byliquidscintillation. The minimum detectable level for133
Xe was approximately 5 picocuries per cubic
meter.
Long Term Response

On April 13, EPA was assigned responsibility for
coordinating all long term Federal surveillance activi-

ties and for preparation of a report to the Presidential Commission investigating the accident at TMI.
EPA developed a long term interagency monitoring
program that is being carried out by a number oforganizations. EPA's report to the Presidential
Commission, containing all of the offsite radiological
data obtained during the accident until May 1, 1979,
i s contained in a six-volume compendium from the
EPA data file.

I nitiation of Involvement

At 10:30 a.m. on March 28, FDA's Bureau of Radiological Health (BRH) received a report from the
NRC that at about 4:00 a.m. an incident possibly
creating a radiation problem had occurred at TMI.
BRH offered assistance to the Pennsylvania Department of Health and the Pennsylvania BRP. Followi ng a meeting Friday, March 30, between representatives of the White House, EPA, the NRC, andHEW, HEW became extensively involved in
responding to TMI.

6. DEPARTMENT OF HEALTH, EDUCATION,
AND WELFARE

Description of Response

General Responsibilities

On March 28, five HEW staff members were onsite at TMI. The following week 51 HEW people
were onsite and others were in various support
roles outside the TMI area. HEW committed extensive resources to the effort and as of July 6, 1979,
HEW had expended approximately 20.4 personyears on the Three Mile Island accident. HEW also
i ncurred considerable costs; as of July 6, 1979,
HEW had allocated about $775 345 to its TMI
response, approximately $400 000 of which wasspent to obtain a sufficient supply of potassium
iodide for the Three Mile Island area resident population should circumstances have warranted its distribution.
The following is a detailed summary of HEW's
TMI-related activities.

HEW's role in control of radioactive contamination of food and in other emergency actions during
the Three Mile Island nuclear accident was delineated in a Federal interagency agreement issued by
the FPA (now part of FEMA) and published in theFederal Register on December 24, 1975. Thisagreement charged HEW with the following:

1. Issuing guidance necessary for evaluating andpreventing the radioactive contamination of foodand animal feeds.
2. Formulating recommendations on, and facilitating
the use of, prophylactic drugs to reduce radiationdose to specific organs (this refers, in particular,
to the use of potassium iodide following a contaminating accident).
3. Providing guidance on emergency radiation
doses related to health and safety of health personnel and assisting State health departments
and other professional organizations in developi ng plans for the prevention of adverse effects
from exposure to radiation.

Within HEW, the above responsibilities are principally carried out by its Food and Drug Administration. FDA's goals are to ensure that food for humanconsumption and animal feeds are safe, pure, andwholesome; that drugs, medical devices, and biological products are safe and effective; that cosmetics
are harmless; and that human exposure to potentially injurious radiation is minimal. FDA also assists
State health officials and other health organizations
on radiation matters.
In addition to FDA activities, HEW, through its
Communicable Disease Center (CDC), and its National Institutes of Health (NIH), acts under a general
responsibility for gathering health effects information.
*Three Mile Island Nuclear Reactor Accident of March 1979,
Environmental Radiation Data, volumes 1-6, September 7,
1979.

FDA Sampling Activities

FDA's milk, food, and water sampling program
was initiated March 29. From March 29 throughJune 30, 1979, 2 037 samples were collected andanalyzed by HEW for radionuclide concentrationlevels (see Appendix Table III-1). Of the samples
Appendix TABLE 111-1. Items sampled fromMarch 29 to June 30, 1979

Food
Bread, butter, cake, donuts, cookies, candy,
cereal, cheese, cole slaw, eggs, fish, flour, fruit
punch, ice cream, market food basket, noodle
products, pastry, peanuts, peanut butter,pretzels, soft drinks, sugar, vegetables
Water
I ntake, potable, river, treated

Milk
Raw, composite, condensed, skim, low-fat,pasteurized, raw goat's

Other
Hay, grass, silage, animal thyroids, animal feed1178

collected by the FDA, 1339 were milk, 525 food,
149 water, 14 animal feed, and 10 miscellaneous.
There were 5 718 analytic tests performed on 2 037
samples. Between March 29, 1979, and April 20,
1979, 69 samples-all milk-were reported positive.
(One additional milk sample was "spiked," as acheck for the quality assurance program; it wasreported positive on April 27, 1979.) No positive
samples of any kind were reported after this date.
Radiation Dosimeters

As of April 2, 1979, FDA had placed 237 TLDs at
173 sites over a 20-mile radius around the reactor.
Most of these dosimeters were situated within a
10-mile radius of the site. Most were placed nearpublic buildings such as schools and hospitals andsome were at homes. At 64 sites dosimeter packages were placed both indoors and outdoors toevaluate the shielding effects of the structures.
Photographic Film Dosimetry

FDA initiated a retrospective dosimetry program
by collecting samples of readily available, 35-mm
Kodacolor 400 film from retail shops in the vicinityof the Three Mile Island facility. This film wasrecommended by Kodak as being relatively radiation
sensitive.
Samples of the film known to have been locatedi n the vicinity of the reactor site during the accident
were collected in early May from stores in or near
Elizabethtown, Manchester, Steelton, New Cumberl and, and Middletown, Pa. Reference samples offil m bearing similar expiration and, hence, similar
manufacturing dates were collected during the same
period in Rockville and Frederick, Md. Eastman Kodak, in cooperation with the FDA, developed thefil ms on May 9 and May 17.
BioassayAt the request of NIH, the Pennsylvania State
Health Department collected urine specimens from38 individuals residing within 5 miles of the Three
Mile Island reactor. The 171 samples were collectedfrom April 4 to April 8, and were delivered daily to
NIH for analysis. The radionuclides potentiallyreleased to the environment from the Three Mile Island reactor were isotopes of the noble gases krypton and xenon, the iodines, cesium, strontium, barium, lanthanum, and ruthenium.
Health Census

The Center for Disease Control (CDC) and the
National Cancer Institute are providing funds for a
project to record names, vital statistics, and relevant

1179

health data for each of the 50,000 people living
within 5 miles of the reactor during the event. Other
facts relevant to determining the amounts of radiation that this group may have received are also being collected. This health census, begun on June
20, 1979, is being conducted by the Pennsylvania
State Health Department and CDC. It will form thebasis for future physical and mental health studies.
As of July 5, 1979, 85% of the targeted households
had been surveyed.
Thyroid Blocking Agent

Following the Three Mile Island accident, the FDA
arranged for the manufacture and stockpiling in Harrisburg, Pa., of potassium iodide solution for use asa thyroid blocking agent to prevent the uptake of radioiodine. FDA's Bureau of Drugs obtained 250,000
ounces of potassium iodide solution, packaged in
1-ounce bottles. Each bottle had a sufficient quantity of iodide solution to accommodate the needs of ahousehold of four throughout the incident. The
Bureau of Drugs had 250,000 patient information
sheets printed and shipped to Harrisburg so that
one could be distributed with each bottle of thesolution.
HEW recommendations with respect to thyroid
blocking were sent to the White House on April 3,
and were then forwarded to the Commonwealth ofPennsylvania. HEW recommended that the Commonwealth do the following:

1. Have workers in the plant and others on the isl and begin taking blocking doses right away.
2. Have potassium iodide immediately available to all
persons whose proximity to the site is such(perhaps up to 10 miles) that they would not haveat least 30 minutes advance warning of 13) exposure.
3. Have potassium iodide available at convenient
points for distribution to other persons who might
be exposed, such that they could have the medication at least 30 to 60 minutes in advance ofpossible exposure.
4. Accompany all distribution with notification to theeffect that: "All persons may take potassium
iodide safely for a short time. All persons who:a) have goiter or known thyroid disease; b) are
pregnant, or c) are breastfeeding a child, should
notify their physician when they start taking
i odide and after they have stopped."
5. Prepare for reducing the iodide dose after 2
weeks of administration of the dose specified on
the labels. HEW offered to help devise instructions to this effect.
6. Those in immediate touch with the local situation
should assess these recommendations in light ofknowledge about current risks and about thelikelihood of advance warning of radiation
releases.

A list of conditions under which use of the drug
should be considered also was available in a publication of the National Council for Radiation Protection and Measurements, NCRP Report No. 55.
Upon consideration of HEW's recommendations, the
NCRP report, and the advice of consultants thePennsylvania Department of Health decided to holdthe drug in readiness, but not to administer it, since
the conditions outlined in the NCRP report were notencountered during the accident.
The potassium iodide sent to TMI has beentransferred to the National Center for ToxicologicalResearch, in Jefferson, Ark., for long term storage.
Periodic stability testing will be conducted to determine when the potassium iodide no longer meets
USP standards, at which time it will be disposed of.
7. THE WHITE HOUSE

White House involvement in the response to theThree Mile Island accident began on Wednesday,
March 28. At about 9:00 a.m., Jessica Tuchman
Mathews, who was then on the staff of the National
Security Council, received a call from Commissioner
Victor Gilinsky of the NRC notifying her that there
had been an incident at Three Mile Island. The information was sketchy, but Gilinsky was aware thatthe plant had tripped, that there was radiation inside
the containment building, and that a general site
emergency had been declared. Mathews drafted abrief memorandum detailing the sketchy facts she
had obtained to Zbigniew Brzezinksi, her superior
and the President's national security advisor. She
hand-carried the memorandum to Brzezinski and,after a brief discussion with Mathews, Brzezinski informed the President of the incident. Throughout
Wednesday and Thursday, Mathews stayed in telephone contact with Gilinsky so that she could keep
up-to-date on plant status. There was no otherWhite House activity at that time.
On Friday morning at about 9:00 a.m., Mathews
was notified by the White House Situation Roomthat they had received a wire service notification of
a 1,200 mR/h release measured in the plume overthe plant. Almost simultaneously, she received atelephone call from Gilinsky with the same information, and immediately informed Brzezinski, who inturn informed the President.
The President telephoned Chairman Joseph Hendrie and asked him what the NRC needed to help
cope with the situation. Hendrie told the President' it there were communications problems; the1180

President promised to provide assistance. Hendrie
had already discussed with Denton, Director of Nuclear Reactor Regulation in the NRC, the possibility
that Denton would go to the site. When the
President, during his conversation with Hendrie,suggested the need for a senior Federal official at
TMI, Hendrie told him that Denton was ready to go.
They agreed that Denton would go to the site as the
personal representative of the President.
At about 11:00 a.m., Mathews and Col. William
Odom, military aide to Brzezinski, briefed Jack Watson, Assistant to the President for Intergovernmental Affairs and Secretary of the Cabinet, and his
deputy, Eugene Eidenberg. Following this briefing,
Mathews briefed Jody Powell on the situation. During her meeting with Powell, she learned that the
President had been in touch with Governor Thornburgh, and that the President's directive regarding
communications had been expanded to include theGovernor's office, so that it would provide a direct
link between the White House, the NRC, the site,
and the Governor's office.
The White House Communications Agency(WHCA), a military communications unit of the Defense Communications Agency, assigned to support
the Executive Office of the President, was the agency responsible for establishing those direct telephone links. Commander Baker of the WHCA proceeded to Harrisburg on Friday afternoon by Marine
Corps helicopter. He arrived within minutes of Denton. By using long-haul trunk lines already available
through AT&T, Baker tied the White House switchboard directly to two lines at the NRC trailers, oneline at the Governor's office, one line to Hendrie at
the NRC Headquarters, and one line to the NRC Incident Response Center. Using this dedicated net,
any one of these telephones automatically rang theWhite House switchboard, from which it could betied either to another telephone on the net or tolines off the net. This dedicated circuit remained inplace and in use for nearly a month.
A Federal agency meeting was held in the WhiteHouse Situation Room on Friday afternoon. It was
attended by representatives from the NRC, FDAA,FPA, DCPA, DOD, and DOE. Hendrie briefed thegroup on plant status. He described the plant asthen being in a stable condition, but emitting small
discharges of radioactivity which were likely to continue. He mentioned the hydrogen bubble anddescribed the hazard it posed in attempts to bring
the reactor to cold shutdown, and the possibility of
having to evacuate people from within 20 miles
downwind of the plant. He also reported that theGovernor had advised a limited evacuation of pregnant women and young children from within 5 milesof the plant.

During the meeting, it was agreed that Watson
would take the lead in coordinating the overall
Federal response effort. This was a normal role for
Watson in his position as Assistant to the President
for Intergovernmental Affairs. He had performed asimilar function during the strike by the United Mine
Workers in early 1978, a strike that had caused
shortages of coal for power generation, and during
the fuel shortage in the spring of 1979, when hecoordinated the efforts of several Federal agencies
i nvolved in fuel allocation. During a subsequentmeeting in Watson's office, it was decided that
DCPA would send John McConnell to Harrisburg toassist in the preparation of evacuation plans; FDAA
would assume the lead for the overall Federal nontechnical response and would send Robert Adamcik
to Harrisburg to coordinate this effort.
The question of whether there should have been
a formal declaration of an emergency or disaster at
TMI was an open issue beginning Friday afternoon
and extending through the weekend. In general, theFederal agencies, particularly FDAA, initially pressed
for such a declaration because they believed it
would facilitate their support activities.
The
Governor's staff did not think it would be advisable,
because the declaration would have an adverse
psychological impact on TMI area populace. At thesame time, however, State officials were prepared
to ask for a formal declaration, had such an act
been necessary to assure the needed Federal assistance. The White House staff, primarily Watson,
obtained assurance from the Federal agencies thatfull assistance was being provided without the formal declaration, even though the lack of a formal
declaration may have caused some administrative
problems. Watson assured the Governor that they
were providing all possible assistance. At the sameti me, however, the White House was prepared to issue a formal declaration almost immediately had theGovernor requested such action. The final decision
whether to request a declaration was left to theGovernor.
Following notification of the release of radioactivity on Friday morning, the health agencies of HEW
and EPA became convinced that they should be involved in the response. A meeting was held at HEW
on Friday afternoon at 3:00 p.m. to discuss the situation. Mathews represented the White House.
On Saturday morning, Secretary Califano of HEW
sent a memorandum to Watson reporting on the
results of the meeting and recommending that, unless the NRC could provide firm assurance that thereactor was cooling safely, Watson should recommend to the Governor an immediate evacuation out
to 20 miles from the plant. Watson discussed thememorandum and the recommendation with Eiden1181

berg, Mathews, and Frank Press, the President's
science advisor. He also called Denton. The consensus of all these individuals was that evacuation
was not necessary. In Watson's view, Denton held
the decisive vote in such a recommendation.
Late Saturday afternoon Watson chaired asecond meeting of the involved Federal agencies in
the White House Situation Room. Commissioners
Gilinsky and Bradford represented the NRC at themeeting. During the meeting, the NRC reported that
preliminary calculations indicated that the likelihoodof a hydrogen explosion was not an immediateproblem, but that it could be a problem in the next
few days. Watson asked that press statements not
be made by the agencies, but by the White Houseor the State officials only.
On Saturday evening an AP wire story regarding
a possible hydrogen explosion broke at about 9:00
p.m. The AP wire was based upon information fromthe NRC Washington offices and appeared to conflict with the information that had been given out
from the site. After much discussion between the
White House and the NRC, the NRC press center in
Washington was closed and future press releases
from the NRC originated from the site.
Watson called Herman Dieckamp, President ofGPU, and suggested that the utility discontinue
separate press briefings. Dieckamp agreed to do
so. In fact, Walter Crietz of Met Ed had already announced earlier in the day that the company would
not hold further press briefings. Later that evening,
during their second joint press conference, theGovernor and Denton attempted to dispel any anxiety that had been generated by the AP wire story.
On Saturday evening the President decided tovisit the site on Sunday. The reasoning behind thisdecision is not clear; at the time, the NRC was very
pessimistic. The hydrogen bubble was believed tobe approaching an explosive mixture and it was
uncertain whether an evacuation might have to beordered. Victor Stello of the NRC was contacted at
the site by an unidentified person from the WhiteHouse, who wondered if it was safe for the
President to visit. Stello said he thought the visit
could be conducted safely. Hendrie was notified of
the visit, but was not asked for his opinion regarding
safety. Watson notified the Governor of the
President's plans later that evening.
The President and Mrs. Carter, accompanied by
Watson, arrived at the Harrisburg airport Sunday
afternoon at about 1:00 p.m. Denton briefed thePresident after his arrival. At the time, the NRC was
still split on its views of the potential for explosion of
the hydrogen bubble. Stello considered an explosion to be impossible, while Roger Mattson of the
NRC still felt it was possible.

The President's party proceeded to the plant fora tour and the President subsequently held a briefpress conference. Later that day, the NRC concluded that there was no danger of a hydrogen explosion.
The WHCA provided its normal support to the
President during his visit to the site. Baker and acommunications team took an auxiliary switchboard
to Harrisburg, arriving at about 6:00 a.m. Sunday
morning. Adequate communication lines were set
up prior to the President's arrival.
On Monday, April 2, as a result of questions
raised by Jay Waldman and others in the
Governor's office, Eidenberg at the White House requested the Public Health Service to prepare
recommendations regarding the advisability of prophylactic administration of potassium iodide. In
response to this request, on April 3, Califano sent amemorandum to Watson, attaching the Surgeon
General's recommendations with respect to thyroid
blocking. Recommendations to distribute potassiumi odide to the public and to administer it to people onsite, which Califano stated had the support of the
Director of the National Institutes of Health, theDirector of the National Cancer Institute, and theCommissioner of the Food and Drug Administration,
were transmitted to the Governor's office by notefrom Watson. In subsequent discussions with
Waldman, Eidenberg was informed that the State
had different advice from its own experts and had
decided not to follow the Califano recommendations.
On April 13, Watson sent a memorandum to
Secretaries Califano (HEW), Schlesinger (DOE), and
EPA Administrator Costle, assigning EPA the leadrole for long term environmental monitoring of theradiation levels around the plant, with assistancefrom HEW and DOE.
I n summary, the White House played a passiverole during the first 2 days following the accident-a
period during which it was believed that the situation
at the plant was under control. However, beginningon Friday morning, March 30, the White House became actively involved in coordinating the Federal
response effort. The White House did not direct
agency efforts; however, it did solve some coordination problems and assure that the Federal
response would be effective. Some of this coordinating activity was necessary because of the lack of
a declared emergency. Beginning on Monday, April
2, the crisis atmosphere began to diminish and theefforts of the White House decreased accordingly,
becoming focused on the long term actions thatwould be required in support of the State and theplant recovery effort.

8. AMERICAN RED CROSS
Organization, Responsibilities, and Authorities

The American Red Cross (ARC) was charteredby Congress in 1905 and charged with two specifictasks: disaster relief, and service to the military.
The Red Cross has taken on other responsibilities in
addition to these two, but the extent of its additional
undertakings varies from chapter to chapter. The
two basic services of the Red Cross are provided
by all chapters.
There are about 3000 Red Cross chapters
throughout the United States. Chapters are generally, but not exclusively, organized on a county
basis. Each chapter is semiautonomous, and isheaded by a volunteer board of directors. The leveli mmediately superior to the chapter is the division,of which there are 60 within the United States.
Above the divisions are four field offices, which arestaffed by employees of the national organizationand headed by a manager. The National Chapter isheaded by a board of governors, of which the
President is the Honorary Chairman. The board
sets policy for the local chapters, divisions, and field
offices. The authority of the National Board ofGovernors is based on their control of funds andtheir authority to remove the charter from a local
chapter.
During the accident at TMI, the operative organization and the channel of communications within the
ARC was from the Harrisburg Chapter to the Philadelphia Division to the Eastern Field Office.
I nitiation of Involvement

On March 28, 1979, the Eastern Field Office wasadvised by Ed Koast, Chapter Manager in Harrisburg, through the Philadelphia Division, that an accident had occurred at TMI, but that there was noreal problem. It appeared at that time that any Red
Cross involvement would be within the capabilitiesof the local chapters.
Description of Response

Koast had been in contact with PEMA officials
and was aware that about 16 000 persons could be
affected by a 5-mile evacuation. There was no realconcern within the field office until Friday morning,when the potential problems at TMI seemed capableof outstripping the resources of the chapters and of
the division. As a result, Daniel Prewitt, Assistant
Director for Disaster Services in ARC's Eastern

1182

Field Office, went to Harrisburg on the evening ofFriday, March 30. With his arrival, the National
Chapter took control of all Red Cross operations relating to TMI; all subsequent decisions were madeby Prewitt or his staff.
Prewitt was first briefed by the Harrisburg
Chapter disaster staff. A shelter had already been
set up by the chapter in the Hershey Arena in
Hershey, Pa., to care for those who had been evacuated under the Governor's advisory relating topregnant women and preschool children. The
shelter operation remained wholly a chapter function. Shortly after his arrival at the Harrisburg
chapter office, Prewitt requested National Headquarters to send a team of mass care specialists toassist in the Red Cross efforts. The initial teamconsisted of an emergency mass care officer from
National Headquarters and 16 disaster specialist
volunteers from various divisions and chapters.
They began arriving in Harrisburg on March 31. The
team ultimately grew to include 35 people.
By this time, PEMA had identified 21 host counties that would be prepared to receive and care forpotential evacuees from the 20-mile evacuation
zone. Specific resources available within each ofthese counties would need to be identified, so masscare specialists were sent into the field to begin
contacting local Red Cross and emergency
management agency representatives to ask for assistance in specifically identifying shelter or congregate care facilities. The specialists also requested
local Red Cross chapters to identify manpower requirements. The information gathered was thenused to determine the adequacy of the congregate
care facilities and the degree of outside manpower
support that would be needed to staff and maintainthese facilities.
Early in the operation it became obvious that thekey to quick Red Cross response was a prior written agreement between the ARC and the State ofPennsylvania. The ARC and PEMA jointly determined that civil authorities would have the responsibili ty for the evacuation, including planning theroutes, performing the evacuation, establishing andmaintaining receiving centers, and directing evacuees to the designated civil defense shelter areas. It
would be the responsibility of the ARC to operate
and maintain ttvese facilities. Tttie Red Class would
also assist, within its capabilities, in the staging andreception centers. This agreement was confirmedby letter from ARC's Prewitt to Oran Henderson, theDirector of PEMA, on April 4,1979.
A cursory review of the level of preparedness inthe host counties revealed that the majority of the1183

Red Cross and civil defense units had very generaland basic plans, and the bulk of these included theidentification of large buildings, primarily publicschools, as congregate care facilities. The units did
not however, have adequate contingency plans forproperly staffing these facilities. Many small communities had only identified small units that could
house fewer than 100 people. Though most of theunits thought they could handle the situation, if
necessary, specifics were not available. The communities that had experienced major flooding within
the preceding 5 years or so were more prepared formass care; however, their plans did not provide forreceiving evacuees from outside their area and were
geared more to natural disasters that damage property, such as a floods or tornados.
Working with local Red Cross and civil defense
officials, and with PEMA representatives, the Red
Cross mass care specialists began identifying possible congregate care facilities. Each facility thatthey determined was feasible for use as a congregate care shelter was checked by the Pennsylvania
Department of Environmental Resources to determine its suitability. Shelters were basically categori zed as either able to hold more than 100 people, or
suitable for fewer than 100 people. The larger facilities were assigned a priority based upon thenumbers of evacuees each could accommodate;smaller facilities were counted only as contingency
planning facilities. The intent was to use the larger
facilities first, so that the maximum number of people would be accommodated in the minimum
number of shelters. Because the occupants ofthese facilities were expected to be generally ingood health and capable of taking care of themselves, in contrast to evacuees in other disasters
where casualties might be expected, minimal staffi ng was planned for the shelters.
Working in this manner, the Red Cross in conjunction with the State, was prepared to open some
596 evacuation centers that could accommodate
about 294 000 people. In addition, the Red Cross
was prepared to supply 75 000 blankets, 15 000
cots, 150 nurses, and 300 volunteers to supplement
State resources. Actual mass care center operation
was limited to the shelter at the Hershey Arena,
which cared for an average of 150 people a day.
l-lersksey Arena had a peak occmancy of 173 on
April 4.
Since the accident, the Red Cross has urged its
local Chapters to better identify and categorize possible mass care facilities within chapter areas.
Several problems overshadowed the Red Cross
response. Because there never was a formal decla-

ration of a disaster at TMI, there was some question
as to whether the Red Cross could or should treat it
as a disaster. This question apparently extended
also to other volunteer organizations that normallyare quick to respond to disasters. A further probl em was that the Red Cross did not know how longit would have to operate the mass care centers.
During other disasters the Red Cross can plan thatpeople will leave the shelters in about 10 days, but
at TMI they did not know how long the evacuation
would last or even if residents would ever be able toreturn home. Prewitt estimated that if the evacuation had taken place, the Red Cross could havespent about a million dollars a day for mass care-afew days of this operation would have taken a substantial part of the ARC's annual budget, which allocated $29 million for disaster relief.

9. CIVIL AIR PATROLThe Civil Air Patrol (CAP) is a volunteer organization that has no officially recognized duties in thedisaster response area. However, the CAP is noted
for the assistance it has provided in various emergencies across the Nation. Two elements of the
CAP were active in response to the TMI-2 accident.
The Capital City Cadet Squadron, located at the
Capital City Airport in Harrisburg, provided auxiliary
security services by assisting the airport police fromMarch 31 to April 3 and from April 6 to April 8. Witha total membership of about 60, the squadron maintained 10 to 15 members on duty at the airport,
sometimes 24 hours a day. Over the weekend of
March 31, 20 to 30 members were present.
Group 1100 of the CAP, which is the parent organization for several CAP squadrons in the Readi ng, Pa., area, acts as an arm of the Berks County
Emergency Management Organization.
Berks
County was designated as a host county in theevent an evacuation had been ordered. Group 1100
personnel assisted in manning the county Emergency Operations Center from March 29 to April 2
while the center was open 24 hours a day. Group
members also participated in planning for receipt
and care of possible evacuees.
10. CONSOLIDATED RAIL CORPORATION(CONRAIL)The Consolidated Rail Corporation (CONRAIL)
has no designated functions to perform in response
to a radiological emergency. However, the Superin-tendent of the Harrisburg Division of CONRAIL, Mr.
Lageman, became aware of the TMI-2 accident via
media reports and contacted PEMA officials on his
own to determine what impact the accident would
have on CONRAIL operations and to offer
CONRAIL's services, if needed.
Lageman became actively involved in emergency
response on Saturday, March 31, when he was
asked by representatives of the Pennsylvania
Department of Transportation to arrange for railtransportation to assist in the evacuation. He spent
most of Saturday, March 31, and Sunday, April 1, in
PEMA headquarters, directing his efforts towardsupporting Dauphin and Cumberland Counties' inplanning for evacuation. By April 2 he had arranged
for four 10-car electric trains, each capable of handling 1000 people, to be made available on 6 to 8
hours' notice, for movement to the east. He also
had arranged for a diesel train of 10 cars, able tocarry 600 people, to be made available on 8 hours'
notice for movement to the north or west. Lageman
had available two diesel-engine trains of 20 to 25
boxcars, which could have been used for evacuation to the south in support of the Cumberland
County evacuation plan.
11. DEPARTMENT OF AGRICULTUREUSDA is one of the 13 Federal agencies signatory
to IRAP. The purpose of IRAP is to provide for,among other things, prompt and effective radiological assistance as may be needed for the protectionof health, safety, and welfare from radiological hazards resulting from radiological incidents. Thus,
USDA has designated individuals in a nationwide
network to use USDA's resources in a crisis.
Among USDA's responsibilities is that of assuring
the consumer that foods are safe and wholesome.
Federal inspection is provided for all meat, poultry,
and related products processed by plants shippingi n interstate and foreign commerce. The work includes inspection of poultry and other animals at theti me of slaughter and of processed products during
various stages of production and handling to assure
wholesomeness of products and truthfulness in labeling.
During TMI the USDA was not called on as a signatory of TRAP nor was its organized network of
emergency personnel called on to participate in theemergency response. The USDA became aware of
the TMI incident through media reports and independently initiated its response.
At noon on Friday, March 30, the USDA ordered
all Federal packing plants within 5 miles of TMI to1184

cease receiving and shipping meat. This action was
taken to prevent possible radioactive contaminationof meat and poultry products. The USDA lifted thisprohibition on Monday morning, April 2, upon receivi ng radiological information from the Pennsylvania
Bureau of Radiation Protection. The USDA also
made available communication equipment to the Environmental Protection Agency and took part in theFederal Regional Council planning for studies of thei mpact of the incident on TMI area farmers and on
food processing and distribution.
12. BUREAU OF LAND MANAGEMENT,DEPARTMENT OF THE INTERIORThe Department of the Interior became involvedin the TMI response through the actions of the
Boise Interagency Fire Center, part of the DOI's
Bureau of Land Management. The Interagency Fire
Center is a group made up of six Federal agencies.
Its principal mission is to provide emergency
response to fires in the Western United States.
On March 31, at 1:25 p.m., the NRC called the Fire
Center and requested a communications officer andtechnicians, together with communications equipment, to be sent to TMI as soon as possible.
By 3:30 p.m. on March 31, the Fire Center's communications equipment, including about 250 radios,and 6 of its people were enroute to TMI in theCenter's aircraft. The communications officer camefrom Atlanta. They arrived at the Harrisburg Airport
late on March 31. The equipment was operational
by April 1, and it was used principally for communications between persons doing radiation monitoringi n the vicinity of TMI and persons at the base station
at the airport.
The last of the Fire Center's personnel returned
home with the equipment on April 23. The approximate cost of the Fire Center's response was$27000.
13. DEPARTMENT OF DEFENSE
Organization, Responsibilities, and Authorities

DoD is responsible for providing the militaryforces necessary for the security of the UnitedStates. Included within DoD are the Department of
the Air Force, the Department of the Army, and theDepartment of the Navy (which includes the U.S.
Marine Corps). In addition to its national security
role, DoD is also charged with participating in planning for civil and domestic emergencies and withcoordinating and monitoring atomic energy mattersaffecting DoD.
DCPA, a separate agency within DoD, carried out
most of the DoD functions concerning civil anddomestic emergencies and related emergency planning. However, DoD also has emergency responsibilities in its own right, which it retains, even though
DCPA functions have now been transferred to FEMA.
DoD is a signatory to IRAP. IRAP contemplates a
DoD role primarily in the context of assistance in theevent of an accident involving a nuclear weapon.
However, the overall capabilities of DoD are suchthat support also could be provided in the event ofan accident at a fixed nuclear facility.
The radiological assistance capabilities of the
DoD are coordinated through the Joint Nuclear Accident Coordinating Center, which is staffed jointly
by DoD and DOE. While each of the military services is responsible for the nuclear material under
its control, the Army has responsibility for responseto any radiation accident of such consequences as
to constitute a domestic emergency.
DoD also has been assigned responsibilities
under FRPPNE, issued in interim form in April 1977.
Under the provisions of FRPPNE, as applicable to
fixed facility nuclear accidents, the DoD is responsible for the following:
1. Providing military assistance, both in the form of
manpower and other resources, in support of andas requested by civil authorities, subject to therequirements of the military mission and within legal parameters.
2. Coordinating and controlling the use of militaryforces made available to civil authorities during
an accident.
I nitiation of Involvement

On Wednesday morning, March 28, at 10:30 a.m.,the Department of Energy Emergency Operations
Center (DOE EOC) notified the National MilitaryCommand Center (NMCC) of the TMI-2 accident.
The NMCC, in turn, notified the Assistant to theSecretary of Defense for Atomic Energy, Dr. Wade,
who has overall DoD responsibility on nuclear
matters.
Description of Response

At 12:25 p.m. on March 28, an Air Force heli copter from the 1st Helicopter Squadron at Andrews Air Force Base in Maryland was dispatchedto carry Aerial Measuring System/Nuclear Emer1185

gency Search Team (AMS/NEST) personnel stationed at Andrews to the site. This was the only immediate DoD response to the accident. For the restof March 28 and all day on the 29th, the NMCC
maintained contact with the DOE EOC to stayabreast of plant status.
On March 30, DoD was represented at the afternoon meeting of Federal agency officials at theWhite House. Following that meeting, Colonel
James Lampros, an Army officer from Fort Dix, N.J.,
was sent to Harrisburg by Robert Adamcik of the
FDAA to serve as the DoD contact in connection
with the coordination of Federal agency response.
Requests for military assistance from Adamcik were
forwarded by Lampros to the NMCC at the Pentagon for action.
On March 31 an Air Force C-5 cargo plane wasused to ship a rawinsonde (a device used to determine the velocity of winds aloft), from McConnell Air
Force Base, Kans., for use by National Oceanic andAtmospheric Administration personnel in making
upper air measurements in Harrisburg. On thesame day, an Army convoy of nine trucks was used
to ship lead bricks from the National Bureau ofStandards in Gaithersburg, Md., to the site for use inshielding the hydrogen recombiner. On March 31
and April 1, four C-141 flights moved other leadbricks from DOE's Brookhaven National Laboratory
and other Federal sources to the site. On March 31,
an Air Force C-130 moved potassium iodide from
Decatur, Ill., to Harrisburg, and an Army tractortrailer brought medicine droppers to Harrisburg from
Buena, N.J. The same day, three Army tractortrailers moved DOE communication pods from Philadelphia to Harrisburg. On April 1 a mechanical robot
was flown by C-5 to Harrisburg from Eglin Air Force
Base, Fla. Water samples from the plant were flown
to Pittsburgh, Knoxville, and Idaho Falls, on April 2,
10, and 14, respectively, for analysis. On April 7 and8, six aircraft were used to ship charcoal filters from
Pasco, Wash. to Harrisburg.
On March 31, when it appeared that evacuationof the site might be ordered, the Army madepreparations at Carlisle Barracks, Pa., to handle the
NRC and DOE support personnel who would haveto be evacuated.
The Army had located 315 ambulances and anumber of fixed-wing aircraft that could have been
made available within hours to expedite evacuation.
The Army also had located and was prepared tosupply cots and blankets to help equip the masscare facilities that had been identified by PEMA andthe Red Cross.

14. FEDERAL BUREAU OF INVESTIGATION
Section 221 of the Atomic Energy Act (42 U.S.C.
Sec. 2271) assigns the Federal Bureau of Investigation (FBI), a part of the Department of Justice,responsibility for investigating all incidents of sabotage involving nuclear facilities, weapons, or materials; any theft of nuclear weapons or materials; any
extortion using nuclear components, devices, ormaterials; and any other suspected criminal violations of the Atomic Energy Act.
The local FBI office in Harrisburg, Pa., was notified of the accident at TMI by the NRC on March 28,
1979, as part of NRC's routine notification of other
Federal agencies. On April 2 the FBI initiated an investigation to determine whether sabotage was thecause of the accident at TMI. The investigationconsisted of three interviews: The first, on April 2,
1979, was with and at the request of officials of the
U.S. Labor Party, who alleged that the accident wascaused by sabotage. Agents discussed the information obtained in this interview with an attorney in
the U.S. Department of Justice, who told the FBI
that there was no substance to the allegations andthat further investigation of sabotage by the FBI was
not warranted. On April 4 the FBI interviewed aprivate citizen who had made a statement to an acquaintance questioning whether sabotage had been
considered as the cause of the accident at TMI. Asa followup to this statement, a third interview washeld on April 6 with Harold Denton of the NRC, who
said the incident at TMI was an accident and not theresult of sabotage.
15. FEDERAL REGIONAL COUNCILS

General Responsibilities

Federal Regional Councils (FRCs) were established by Executive Order 11647 on February 10,
1972. A Council was created for each of the 10
standard Federal Regions. Each is composed of theprincipal regional officials of the Departments ofAgriculture; Commerce; Energy; Health, Education,and Welfare; Housing and Urban Development; Interior; Labor; Transportation; the Community Services
Administration; and the Environmental Protection
Agency. The Councils were mandated to improvecoordination of the categorical grant system and todevelop closer working relationships among themselves and with State and local governments.
Executive Order 11731, issued July 23, 1973,
broadened the FRC mandate to include coordination1186

of direct Federal program assistance to State andlocal governments. Executive Order 11892 of December 31, 1975, increased the membership of the
FRC system, toward the ends of further expanding
i nteragency cooperation and improving coordinationof services to State and local governments.
Three broad missions underlie the functions of
FRCs: developing close intergovernmental relations,coordinating interagency programs, and delivering
services such as emergency aid needed duringcrises and disasters.
I nitiation of Involvement

On April 4, Thomas C. Maloney, Chairman of the
FRC for the Pennsylvania area, asked Council
members to determine their respective agency's
ability to respond to the consequences of TMI. For
example, an agency might evaluate the assistancethat it could provide if the tourist industry or farmingi n the TMI area were severely affected by the accident. Following an April 13 meeting with Pennsylvania State representatives at the White House to
discuss possible State needs and Federal assistance, Jack Watson designated Maloney to serve as
lead Federal official for coordinating Federal
response to the ramifications of the TMI incident.
Description of Response

As provided in Watson's memorandum appointing
Maloney lead Federal official, Maloney's responsibilities include "assuring effective communication
within the Federal Government and with the Governor and State officials, identification of problems requiring Federal assistance, delivery of needed andappropriate Federal assistance, and monitoring theeffectiveness and quality of Federal responses."
The memorandum also notes that certain Federal
agencies continue to have direct responsibilities,
which will be performed concurrently with Maloney's
duties. For example, the NRC will continue to havefull onsite responsibility and the EPA will continue tohave the Federal lead for environmental monitoring.
The following is a brief summary of the major
Federal responses to postaccident effects of the
TMI incident that the FRC will monitor.
Small Business Disaster Loans- The Small Business Administration declared the TMI vicinity an
economic disaster area, making small businesses
eligible for disaster loans. Disaster loan offices
were opened in Harrisburg, Middletown, Lancaster,1187

and York. The volume of loan applications was
small. Principally, two kinds of businesses qualified
for loans: grocery stores that incurred losses when
perishables could not be sold because people had
left the area, and retail clothing stores that for similar reasons missed the Easter sales market.
Study on Pregnancy Outcomes-Because of extensive public interest in pregnancy outcomes, HEW
Region III funded a study for the State Department
of Health to begin immediate data collection. The
grant was in the amount of $80000 and covered
the period to September 30, 1979. It has since
been renewed.
Population Census-The Center for Disease Control

and the National Institutes of Health funded a population census through the Pennsylvania Department
of Health of all persons living within 5 miles of TMI
on the date of the accident. The census registry will
be used for any future health studies of the population.
Mental Health Study-The National Institute of Mental Health designed and funded a mental health survey to study the psychological impacts of the TMI
crisis. This will be a long range study concentrating
on workers, young children, and people with previously known mental problems.
Emergency Response/Behavioral
Survey- The
NRC designed and funded a survey to study emergency response and pertinent behavioral issues.
Radiation Monitoring- Several Federal agencies,
with EPA as the lead, have engaged in long term radiation surveillance in the TMI vicinity. This monitoring will continue until cleanup of the damaged reactor is completed.
Emergency Preparedness Review- Federal emer-

gency agencies have been reviewing the adequacyof their own preparedness and working with States
and local officials to improve the emergency systems.
Socioeconomic Impact Study-Several Federal
agencies have awarded approximately $600 000 to
the Governor's Office of State Planning andDevelopment to perform a comprehensive study ofthe socioeconomic effects of TMI. As proposed, thesocioeconomic study focuses on the effects of TMI
i n the following areas: commercial and industrialproduction and employment, agricultural production
and commodity consumption, food processing industries, tourism and travel, new residential andcommercial construction,
housing, community
development, local government budgets, State andlocal revenues, insurance claims against Met Ed,
and coordination of requests for Federal funding. In
addition to the State's studies, the FRC has beenmonitoring the economic impacts of TMI in the Harrisburg area so that it can be prepared to respond if
necessary.
16. INTERSTATE COMMERCE COMMISSION
Organization, Responsibilities, and Authorities

The Interstate Commerce Commission (ICC) regulates interstate surface transportation, including
trains, trucks, buses, inland waterway and coastal
shipping, freight forwarders, and express companies. The ICC is a signatory to IRAP. Under
IRAP, the ICC's response to a radiation emergency
is to assist in arranging and expediting emergency
transportation of people and property moving ininterstate commerce to or from the distressed area.
The ICC also has responsibilities assigned by
FRPPNE. Under FRPPNE, the ICC is responsible forsetting priorities and issuing orders to railroads andgranting immediate emergency operations authority
to motor and water carriers for expediting the surface transportation of people and property to orfrom areas affected by a peacetime nuclear emergency. Under the coordinating authority of theSecretary of Transportation, ICC is responsible forsetting priorities governing surface transportation ofpeople and property by all surface modes.
Initiation of Involvement

The ICC was never called upon for any assistance in response to the TMI accident. Although
PEMA alerted the ICC Regional Managing Director in
Philadelphia, Ivan Schaeffer, to the accident, PEMA
never made a followup contact or request for aid.

18. NATIONAL AERONAUTICS AND SPACE
ADMINISTRATION

Organization, Responsibilities, and Authorities
The principal statutory functions of the National
Aeronautics and Space Administration (NASA) areto conduct research relating to problems of flightwithin and outside of the earth's atmosphere, and todevelop, construct, test, and operate aeronauticaland space vehicles. The considerable capabilities
developed by NASA to achieve these goals could
be very useful in responding to radiation emergencies. The resources that NASA could make available in support of radiation emergencies include:
radiological, environmental health, and medical support personnel; radiation measuring instruments;
l aboratory facilities; firefighting equipment; generators and communications equipment; and various
items of heavy equipment. NASA is a signatory to
I RAP.
NASA also has been assigned responsibilities
under FRPPNE. Under FRPPNE, NASA is responsible for the following:
1. Adapting and using its scientific and technologicalcapabilities as required to meet priority needs ofthe programs of the Federal Government in a nuclear emergency.
2. Assisting, through its satellite capability, in environmental and weather monitoring, establishingcommunications networks, and assessing damages as requested by other Government agencies.

17. MINE SAFETY AND HEALTH
ADMINISTRATION
Among other things, the Mine Safety and HealthAdministration (MSHA), in the Department of Labor,
investigates accidents at all types of mines-metal
and nonmetal mines as well as coal mines. It has
the equipment and experienced personnel to do so.
The equipment includes breathing equipment with
self-contained air supplies.

On April 4, 1979, the NRC requested 24 sets ofoxygen breathing apparatus through the FDAA.
MSHA's Mine Rescue Unit was alerted to the request at 9:30 a.m. on April 4. The unit packed its
equipment and drove 225 miles to the TMI site, arriving by 4:20 p.m. On April 5 it was determinedthat the NRC wanted MSHA's breathing apparatus
as backup for the breathing apparatus they wereusing regularly. During the following week, 6 MSHA
team members trained 30 men to wear the 24 setsof MSHA breathing apparatus and 1 man to keep theapparatus in ready-to-use condition. MSHA personnel then departed TMI, leaving most of theirequipment' ' - w NRC use. The equipment was later
returned to MSHA.

I nitiation of Involvement

1188

NASA was not formally notified of the TMI accident, and did not become involved until April 1. On
the morning of April 1, NASA Administrator Dr. Alan
Lovelace received a call from Dale Myers of DOE

requesting the services of Wilbur Riehl of the
Marshall Space Flight Center as a hydrogen consultant.
Description of Response

In response to the request from DOE, Riehl flew
to Harrisburg by NASA aircraft on April 1. He provided advice and assistance relating to thehydrogen-generation problem until April 3. NASA
had no other involvement in the TMI response.
19. NATIONAL BUREAU OF STANDARDSThe National Bureau of Standards (NBS) provides
the basis for the Nation's measurement standards
that lead to accurate and uniform physical measurement and reliable data throughout the Nation's
scientific, industrial, and commercial communities. It
provides advisory and research services forFederal, State, and local government agencies.
NBS is generally recognized as the U.S. authority inthe area of calibration of radiation measuring instruments.
On March 31, 1979, the NRC requested NBS toprovide lead bricks for the construction of a shieldi ng wall in the TMI-2 auxiliary building. NBS supplied 15 tons of lead bricks, which were picked up
by an Army convoy on April 1.
On April 2 the NRC requested information on hydrogen solubility in water at elevated temperaturesand pressures. Basic physical data was supplied to
the NRC for use in solving the hydrogen bubble
problem.
On April 5, 6, and 9, the NRC, EPA, and DOE,
respectively, requested NBS to calibrate radiation
measuring instruments for xenon. These instruments had been used at TMI. This after-the-factcalibration was obtained in order to determine thevalidity of instrument readings previously obtained.
20. NATIONAL OCEANIC AND ATMOSPHERICADMINISTRATIONWith respect to emergency response to a radiation incident, the functions and capabilities set out
for NOAA in IRAP, to which the Department of Commerce is signatory, include the following:

1. Provision of current information, weather forecasts, and warning advisory services to assist inmeeting radiation emergencies, especially information about changes in wind, boundary layer
mixing, precipitation conditions, and other significant weather parameters.
2. Provision of fallout wind-vector data upon request.
3. Utilization of DCPA equipment at local National
Weather Service field offices to provide gamma
radiation readings if requested by appropriate
agencies.
4. Provision of weather and climate information andadvice for use in planning protective action or relief programs. (National Weather Service Regional Offices provide coordination and planning assistance.)

At 9:00 a.m., March 28, PEMA called NOAA at
the Harrisburg Airport for the wind forecast, and advised NOAA that there had been an accident at TMI.
Beginning on March 28, the NRC requested routine
forecasts, and on or about March 30 requested
more refined forecasts.
During the first 2 days of the accident, NOAA
provided routine forecasts upon request to the NRC,
PEMA, and the DER. The request for more refined
forecasts was answered using upper-air support
teams with special equipment to Pennsylvania. Data
provided by the upper-air teams was used by
DOE's Lawrence Livermore Laboratory to computethe direction and size of the TMI radiation plume.
On April 2, at NOAA's suggestion, PEMA made atape for broadcast over the NOAA Weather Radio
System advising people to listen to various broadcasting system stations in the event of an emergency. This tape was prepared, but PEMA never requested its use.
21. POSTAL SERVICE

Among its principal functions and activities, theNational Oceanic and Atmospheric Administration( NOAA), of the Department of Commerce, reports
the weather of the United States and its possessions and provides weather forecasts to the generalpublic; issues warnings against such destructive natural events as hurricanes, tornadoes, floods, andtsunamis; and provides special services in supportof aviation, marine activities, agriculture, forestry, urban air quality control, and other weather-sensitive

Organization, Responsibilities, and Authorities

The operational group of the U.S. Postal Service( USPS) is organized nationwide into five regions.
Each region is composed of a number of districts
which, in turn, are composed of a number of sectional centers. The vicinity of Three Mile Island falls
within the jurisdiction of the Susquehanna District,which is sudivided into a number of sectional
centers. Two of these, the Harrisburg Sectional
Center and the Lancaster Sectional Center, areactivities.

1189

responsible for postal services in the immediate vicinity of the TMI plant. The Middletown and High
Spire post offices fall under the jurisdiction of theHarrisburg Sectional Center, while the Etters(Goldsboro) and York Haven post offices are within
the jurisdiction of the Lancaster Sectional Center.
USPS is a signatory to IRAP, although the planmakes no mention of the nature of Postal Service
capabilities or of its expected response efforts.
However, under the provisions of FRPPNE, the Postal Service is responsible for the following:

1. Providing emergency mail service in the affectedarea.
2. Registering persons and families, in cooperation
with HEW, to permit State and local welfare
agencies to answer inquiries and reunite families.
I nitiation of Response

The Postal Service was not formally notified of
the TMI accident. The manager of the SusquehannaDistrict, Robert Brown, first became aware of theaccident when he was notified by the postmaster at
Middletown.
Description of Response

The Postal Service participated in coordination
meetings of the Federal agencies on April 1 and 2,
and identified 185 vehicles that could be used in an
evacuation effort. Contact was made with theAmerican Red Cross to establish a locator file fordisplaced persons. Otherwise, as it does in any
disaster, the Postal Service assured that the mailwas properly handled and protected and that its
mail carriers and vehicles were out on the streets,
visible to the populace, in an effort to exert a stabilizing psychological effect.
22. SMALL BUSINESS ADMINISTRATION
Among the responsibilities of the Small Business
Administration (SBA) is the granting of loans to small
businesses; to State and local development companies which, in turn, assist small businesses; andto victims of floods or other catastrophes or of certain types of economic injury. To permit activationof the SBA loan program in response to the TMI accident, it was necessary that a declaration of an
economic dislocation area be made.
On April 27, 1979, A. Vernon Weaver, Jr., Administrator of the SBA, approved the request of
Governor Thomburgh to declare the five-county
area-Cumberland, Dauphin, Lancaster, Lebanon,
1190

and York-an economic dislocation area. The declaration was effective immediately, and continued
during the subsequent 8 months. SBA operations
are carried out through SBA Region III offices located outside of Philadelphia.
Following the declaration of the economic dislocation area, SBA established special offices in Harrisburg, Lancaster, York, and Middletown to handle
claims from local businesses. The office in Middletown was kept open for 2 months. The other special offices were closed in October as the result of al ow level of activity. The SBA branch office in Harrisburg was made available for any necessary TMIrelated business during the remainder of the 8month declaration period. Through October 15, a
total of 59 loan applications, totaling $2 920 000,
were received. One application was withdrawn; 30
have been disallowed; 20, totaling $425 000, havebeen approved; and 8 were still being processed.
23. DEPARTMENT OF TRANSPORTATIONThe Department of Transportation (DOT) includes, as major subagencies, the U.S. Coast
Guard, the Federal Aviation Administration (FAA),
the Federal Highway Administration (FHWA), andthe Federal Railroad Administration (FRA). Thesefour subunits of DOT could participate in response
to a radiation emergency. In addition, the DOT has
designated so-called Regional Emergency Trans portation Coordinators (RETCOs) to become actively involved in transportation aspects of the
response to any emergency, including a radiation
emergency.
I RAP, to which DOT is signatory, provides that in
response to a radiation incident DOT functions consist primarily of notification of Federal and local
agencies (for transportation incidents), arrangements for special transportation activities, and assistance in contacting consignors and consignees ofshipments affected by the incident.
DOT also has responsibilities under FRPPNE,
which provides that, in emergencies at fixed nuclear
facilities, DOT is responsible for preparing anddeveloping emergency programs in coordination
with the Federal transportation operating and support agencies. In addition, DOT is to employ all
possible forms of civil transportation in support ofefforts to handle and mitigate the effects of peaceti me nuclear emergencies. FRPPNE makes DOT
responsible for the following:

1. Developing policies, plans, and programs to ensure that all modes of transportation will be used
as required and to provide a unified, coordinatedtransportation system to meet the requirementsof any peacetime nuclear emergency.
2. Coordinating planning activities of State and local
authorities in adjoining areas for use of intrastatetransportation facilities and services where andwhen required.
3. Coordinating the development of facilities protection guidance material for transportation systems
developed by the modal operating and support
agencies. This guidance is to be directed toward
protection of personnel and facilities of operating
proprietorships, public and private, from the effects of peacetime nuclear emergencies.
4. Providing leadership and executive management
as authorized by law and Executive Order tomodal operating and support elements in coordinating the development of interagency planningto ensure the effective management and use oftransportation resources during peacetime nuclear emergencies.
5. Developing plans and policies for the utilization of
the Coast Guard to meet the requirements ofpeacetime nuclear emergencies.
I nitiation of Response

The DOT Headquarters was never formally notified of the TMI accident. It became aware of the accident on March 28, 1979, through media reports.
Description of Response

Soon after the accident, the FAA established atemporary restricted area for aircraft travel over the
TMI plant and certified a helipad near the plant toaccommodate emergency operations. The Coast
Guard was notified in accordance with the TMI
emergency plan and provided traffic regulation services on the Susquehanna River upstream anddownstream from the plant.
On March 31, John W. Porco, the RETCO, arranged for DOT representatives to attend theFederal agency coordination meetings in Harrisburgthat were chaired by Adamcik of FDAA. Representatives of the FHWA and FAA also attended thesemeetings.
During the evacuation planning period over the
weekend of March 31, FPA consulted Porco by telephone regarding the effects of an evacuation on thetransportation facilities. He recommended that contact be established with CONRAIL and AMTRAK.
During the same period, the FAA activated its Regional Emergency Command Post and advised its
field offices in the Middletown-Harrisburg area tobegin taking radiological readings and to issue do1191

simeters to employees. Radiological readings wereappended to the hourly weather reports by the flight
service sections. A cadre of 24 FAA employees
was prepared to evacuate the FAA facilities. The
FAA offered the NRC the use of its worldwide communications capability, but little use was made ofthe equipment.
During early April DOT became involved in truck
shipments of waste materials from the TMI site.
Three truckloads of waste originally destined for
burial in South Carolina ultimately were rerouted toRichland, Wash., after the State of South Carolina
rejected the shipments.
Beginning April 11 Porco located the owners ofsuitable railroad tank cars that could be brought tothe site to serve as temporary storage facilities forradioactive wastewater. The cars themselves werel ocated, and preliminary arrangements to have thecars moved to the site were made.
The DOT continues to be involved during the longterm recovery efforts, both in shipment of special
equipment and material to the site and in shipmentof waste materials from the site. Each truckload ofwaste is inspected by a FHWA representative prior
to release.

SPECIFIC RESPONSE OF THE
COMMONWEALTH OF PENNSYLVANIA AND OTHER STATESTO TMIThis part of Appendix 111.7 details the organization, responsibilities, authorities, and emergency
response actions of major State and local agencies.
Because of their immediate proximity to the plant
and their basic responsibility to provide prompt andadequate protection of their citizenry, the county
and local agencies are discussed first. Because of
their front line roles in State agency response, BRP(in the DER), PEMA, and the Governor's Office are
discussed after that. Other State agencies follow inalphabetical order. This section closes with an
examination of the role played by States other thanthe Commonwealth of Pennsylvania.
1. COUNTY AND LOCAL JURISDICTIONS
Organization, Responsibilities, and Authorities

The accident at TMI directly affected the six
counties within 20 miles of the plant-Dauphin,York, Lancaster, Lebanon, Cumberland, and Perry.
In addition, over 20 other counties in Pennsylvania

had been designated host counties which would
provide mass care shelters for evacuees from thesix counties at risk. The host counties will not be
discussed here. Because the organization, responsibilities, and authorities of each of the six counties
at risk are the same, this discussion applies to eachof the counties. The response of all counties wasbasically the same; differences among the
responses of specific counties are highlighted.
County notifications are described separately.
The concept of operations envisioned in the
Commonwealth of Pennsylvania Disaster Operations
Plan dated July 12, 1977, is that county and local
governments have an inherent moral duty, as well
as a legal responsibility, to ensure that their jurisdiction is prepared to cope with any disaster situation.
If the county and local governments require assistance, it is provided by the Commonwealth departments and agencies. If two or more counties are affected, PEMA, through its area offices, is responsible for coordination and provision of support to thearea of operations.
The Emergency Management Services Code of1978, as well as the Disaster Operations Plan, clearly require the designation of an emergency coordinator and the development of an emergency planfor each of the 2600 political jurisdictions within the
Commonwealth. While there were only two local
political subdivisions within the 5-mile radius of TMI
that had not appointed an emergency coordinator at
the time of the TMI accident, there were no formal,
l ocal emergency plans in existence.
The Commonwealth Disaster Operations Plan
sets out specific responsibilities for county and local
emergency management directors. These responsibilities include the following:

1. Emergency planning, including plans for the
movement of support forces to disaster locations,movement of people from danger areas, operation of police lines, casualty care operations,mass care operations, highway traffic control,
emergency transportation, public information,
emergency supplies, and resource listings.
2. Training county and local officials.
3. Establishing an emergency operations center.
4. Communications.
5. Assuring sufficiency of emergency manpower.
6. Conducting tests and exercises of the county
plans.
The primary responsibilities of the county emergency director during a nuclear incident are advisingcounty and local government officials and the publicof events having public interest and carrying out, incoordination with local officials, evacuations or other1192

protective measures ordered by the county board ofcommissioners or the Governor.
The top government organization within each of
the six counties at risk is a three-member board ofcommissioners. Each county has an emergency
management agency (variously called the Emergency Management Agency, Office of Emergency
Preparedness, or County Civil Defense) with adirector who reports to the board of commissioners.
I n addition to their disaster planning and management responsibilities, the county directors are
responsible for central dispatch of the county fire,police, and rescue services.
Because the emergency planning zone around
TMI extended 5 miles from the plant (before the accident), only three counties-Dauphin, York, andLancaster-were required to have emergency plansthat specifically accounted for TMI. Each of thesecounties had prepared plans during 1978 at thedirection of PEMA.
I nitiation of Involvement

Dauphin County- The Dauphin County Office ofEmergency Preparedness was first notified of an
onsite incident at Three Mile Island at 7:09 a.m.,
March 28, by Margaret Reilly, Chief of the Division
of Environmental Radiation in the State's BRP. At
7:10 a.m. Dauphin County was notified by the utility,
and at 7:13 a.m. the county was notified by the
PEMA watch officer.

York County- The York County Emergency
Management Agency was notified of the accident at
TMI by teletype from the Lancaster County Emergency Management Center at 7:27 a.m., March 28.
Lancaster County had been requested by PEMA tonotify York County because PEMA was unable tocontact York County by telephone.
Lancaster County-The PEMA duty officer notified

the Lancaster County Emergency Management
Agency of the accident at 7:20 a.m., March 28.

Cumberland County-The Director of the Cumber-l and County Office of Emergency Preparedness was
notified of the accident at TMI by PEMA during aseminar for county coordinators in Selingsgrove,Pa., during the morning of March 28. PEMA had notified the Director's office earlier that morning. Because no part of Cumberland County is within 5
miles of TMI, the county did not become actively involved with the accident until Friday morning, March
30, at 10:00 a.m., when it was advised by PEMA tobegin planning for an evacuation of those portionsof Cumberland County within 10 miles of TMI.

Lebanon County-The Lebanon County Emergency

Management Director was notified by PEMA of theaccident at TMI at 9:00 a.m., March 28. Even
though no portion of Lebanon County is within 5
miles of TMI, the County Radiation Officer immediately began making radiation measurements within
the county. While a very small portion of Lebanon
County is within the 10-mile radius of TMI, Lebanon
County was not advised by PEMA to begin prepari ng a 10-mile evacuation plan. At 5:00 a.m., March
31, PEMA advised Lebanon County to begin prepari ng for a 20-mile evacuation around TMI.

Perry County-Although the Perry County Civil De-

fense Director was aware of the accident at TMIfrom news reports during March 28 to March 30,
Perry County did not become involved until March
31. At 8:40 a.m. that day, PEMA advised Perry
County to begin preparing to evacuate all Perry
County residents within a 20-mile radius of TMI.
Only a small portion of the county lies within the
20-mile radius.
Description of Response

The major activity of the six counties at risk duri ng the accident was preparing evacuation plans.
On March 28, the three counties within 5 miles of
TMI had emergency plans for TMI and wereprepared to implement them if necessary. On
March 30, the planning zone was increased to 10
miles and on March 31 it was increased to 20 miles.
These changes significantly increased the planningrequirements for the three counties with 5-mileplans and imposed planning requirements on threeother counties, which had not expected to be
directly affected by an accident at TMI.
Although there is no general agreement among
the counties and PEMA as to which counties wereadvised to begin 10- and 20-mile planning and when
the advisory was issued, all of the six counties atrisk were actively engaged in 20-mile planning by
Saturday morning. The planning approaches takenby the county emergency management directors
differed among the counties. The approach taken
by Dauphin, York, Lancaster, and Lebanon Counties
was to assemble all evacuation support groups,
such as fire, police, rescue services, and the Red
Cross, and assign them to develop their portions of
the plan. The various segments of the plan werethen pulled together by the County Directors. In
developing their plans, the counties were provided
significant help by PEMA, the State Police, thePennsylvania Department of Transportation, the National Guard, and DCPA representatives assigned to1193

the counties. Local coordinators were then called
together and advised of their areas of responsiblility.
The basic philosophy of these four counties, however, was that planning for the evacuation would becentralized in each county's emergency management agency and that the localities would be assigned specific local planning and implementation
duties.
The philosophy in Cumberland County was different: Cumberland chose to rely largely on local
emergency management coordinators for developi ng the evacuation plans. The County Emergency
Management Director provided a basic plan to thel ocal directors; the plan was to be customized totheir local needs. The county assumed planningresponsibility for all fire and rescue services andevacuation of hospitals and nursing homes so thatthe localities could concentrate on planning to movetheir other residents.
The Perry County Civil Defense Director neverdeveloped a detailed evacuation plan. The Perry
County Director chose to rely largely on his county
resource inventory, which he maintains and which
can be tapped to fit his needs during any emergency. Planning in Perry County was centralized at thecounty level; meetings were held on Saturday,
March 31, with local directors, Government officials,
and emergency personnel to brief them on the plan.
The local representatives were then responsible forholding local meetings to brief residents and toprepare them to evacuate. This more informal arrangement likely was adequate, in view of the verysmall portion of Perry County that was within the
20-mile area.
The county plans were largely completed by
Sunday evening, April 1, although the complete doc uments were not printed and distributed until laterthat week.
The county emergency management agencies
were also a primary source of information and guidance for the public throughout the accident. Everycounty director commented that a significant portionof his time and the time of his staff was spentanswering telephones and responding to publicquestions and rumors. In fact, Dauphin and YorkCounties had to install telephone lines specifically tohandle rumors.
The counties were dependent on PEMA for information. Though the county directors did not believe
PEMA was withholding information from them,
PEMA was unable to answer many of the questions
the counties were asking. The county directors
viewed this breakdown in communications as a major problem and believed it may have resulted in theloss of the counties' credibility from the public's per-

spective. Many times the county directors did nothave time to listen to the media reports, so they did
not even have as much information as many of thecallers.
Both Lebanon and Lancaster Counties statedthat during the accident the county radiological of ficers made radiation measurements in the portion of
their counties closest to TMI. The county officials
used civil defense monitoring equipment originallyplaced in the counties for use in the event of a nuclear attack. Much of this equipment was relatively
high level instrumentation that was not suitable forthe low levels associated with the TMI accident.
The counties did not provide their monitoring results
to any agency outside the county, and did not receive the results of State or Federal monitoring programs.

BRP has 19 professional staff members located in
its Harrisburg headquarters and its Pittsburgh andReading area offices. Most of its personnel are routinely involved in regulatory matters concerning Xrays rather than nuclear powerplant activities, but
BRP does have one nuclear engineer with experience in the nuclear power industry. BRP has a laboratory in Harrisburg for analyzing samples generated by the environmental surveillance program.
I nitiation of Involvement

At 7:05 a.m. on March 28, the BRP duty officer
was notified at home by the PEMA watch officer
that a site emergency had been declared at TMI.
TMI had requested that BRP call the TMI-2 control
room, and the BRP duty officer established contact
with the TMI-2 control room at 7:06 a.m. At 7:25
a.m. the Director of BRP, upon arrival at his office,reestablished contact with the TMI-2 control room:
this connection remained open for about the next 2
weeks, serving as the principal communications link
between the utility and the State.

2. BUREAU OF RADIATION PROTECTION
Organization, Responsibilities, and Authorities

At the time of the accident at TMI, planningresponsibility within the Commonwealth for incidents
at fixed nuclear facilities belonged to BRP, part of
the DER. This responsibility had been documented
i n a 1977 agreement between the Secretary of DER
and the Director of PEMA, which had -responsibility
for planning for other emergencies throughout theCommonwealth.
I n September 1977, BRP issued a "Plan for Nuclear Power Generating Station Incidents." Under
this plan, BRP is responsible for contacting the facility following notification from PEMA and obtaining adescription of the occurrence, the prognosis, andrecommendations. From that point, BRP is responsible for the following:

1. Maintaining contact with the facility.
2. Performing supplementary environmental sampling and analysis.
3. Providing appropriate State, county, and local
agencies with updated information. PEMA would
normally communicate these updating reports toState agencies through the PEMA Emergency
Operations Center.
4. Advising State agencies and county and local
governments, through PEMA, of the need to takeprotective actions, the actions to be taken, thegeographic area at risk, pertinent facility conditions having influence on the emergency, andwithdrawal of protective actions.
5. Notifying and requesting assistance from Federal
agencies having interest and expertise in radiation protection.

Description of Response

BRP's radiological monitoring program began atabout 10:45 a.m. on March 28, when a BRP monitoring team was sent to the site to verify reports
from the utility that small amounts of radiation werebeing detected off site. Because of concern about
the presence of radioactive iodines in the releases
from the plant, BRP advised the Department of Agriculture to begin sampling milk from farms in the TMI
area, beginning with the evening milkings on March
28. The same concern, coupled with the fact that
BRP was not equipped to do radioiodine measurements in the field, prompted BRP to request assistance from the Brookhaven RAP team at 11:18 a.m.
on March 28. Throughout the Brookhaven RAP
team's stay at TMI, their primary function was to assist BRP in its environmental monitoring program.
As the Federal radiological response increasedon Friday, March 30, a need developed to establish
a mechanism to coordinate the overall radiation
monitoring program. At the request of BRP during ameeting on Friday evening, DOE assumed responsibility for coordinating the monitoring results from allagencies. This request was documented in a letter
dated April 6, 1979, from the Director of BRP to the
DOE onsite coordinator.
The BRP monitoring program included sampling
air, water, milk, and grasses. The laboratory isequipped with a multichannel analyzer, two windowless internal proportional counters, one thin window1194

low background proportional counter, and one liquid
scintillation system. BRP's portable radiation detection equipment includes ionization chambers,
Geiger-Mueller survey meters, and pocket dosimeters. In addition, each operating nuclear power station has at least one low volume air sampler locatednear the plant and operated by the Commonwealth.
The samples collected by BRP during the accident
were analyzed in the BRP laboratory. BRP also was
responsible for collecting and analyzing all the radiological data and making recommendations to
PEMA and the Governor for protective actions
based on that data.
Because of the radiation monitoring results, few
protective actions were recommended by BRP.
Early Wednesday morning, March 28, based on highradiation readings inside containment and an esti mated leak rate, Met Ed estimated a 10-R/h radiation level to the west of the plant. As a result, BRP
advised PEMA that it should be prepared to evacuate Goldsboro and Brunner Island. A few minutes
later, however, a TMI survey team determined thatno radiation above background was detectable inGoldsboro, and BRP withdrew its advisory.
The BRP position throughout the accident wasthat radiation levels off site were not high enough towarrant taking any protective actions. BRP did notagree that evacuation was necessary Friday morni ng, despite the NRC's recommendation to PEMA
and PEMA's recommendation to the Governor. Duri ng a meeting in the Governor's office on Friday
morning, the Director of BRP also disagreed that
evacuation of pregnant women and small children
was necessary, but he believed the State had nochoice but to issue the advisory after it had been
recommended by the Chairman of the NRC. The
Director of BRP has explained that because there
were no criteria on which to advise this partial evacuation, there were no clear criteria on which tobase a decision to allow evacuees to return.
The only protective action in which BRP did concur was the issuance of an advisory from the
Department of Agriculture that farmers shelter theircattle and give them stored feed. Agriculture personnel stated that Margaret Reilly, the Chief of theDivision of Environmental Radiation in BRP, concurred in this advisory, although she does notremember doing so. She indicated, however, thatshe did not disagree with issuing that advisory as aprecaution, since forage grasses had not yet begun
to grow and stored feeds were readily available.
Of the 19 professional staff in BRP, 18 were involved in the TMI response. Four of these worked
i n the BRP laboratory. On Friday, March 30, the
BRP nuclear engineer was assigned to the TMI site,1195

12 hours a day, to keep the Governor's Office and
BRP advised of any activity that could cause offsite
consequences. The remainder of the BRP staff washeavily involved in collecting samples and analyzing
the results to determine what recommendations
should be made.
3. PENNSYLVANIA EMERGENCY
MANAGEMENT AGENCY
Organization, Responsibilities, and Authorities

The Emergency Management Services Code,signed into law by the Governor of Pennsylvania on
November 26, 1978, reorganized the Pennsylvania
Civil Defense program. This act established thePennsylvania Emergency Management Council, superseding the State Council of Civil Defense, andgave it responsibility for overall policy and directionof a statewide civil defense and disaster program.
The Council comprises the Governor, the Lieutenant
Governor, the heads of 10 State agencies, and the
majority and minority leaders of the State Senate
and the House of Representatives. The Governor
has designated the Lieutenant Governor to serve as
Chairman of the Council.
The act also provides for a staff, known as thePennsylvania Emergency Management Agency(PEMA), headed by a Director who serves as theCouncil Chairman's principal assistant in civil defense and disaster matters and who performs fiscal,
planning, administrative, operational, and other duties assigned him by the Council. Since passage ofthis act, the Council has not assigned specific duties
to the Director of PEMA; the Director believes, however, that he has overall responsibility for operationof PEMA and has received no indication to the contrary from the Council.
Historically, responsibility for State planning forincidents at fixed nuclear facilities was vested in
BRP as part of the DER under an agreement
between DER and PEMA. PEMA did, however, add
Annex E to the Commonwealth Disaster Operations
Plan of July 1977. Annex E is a plan for responding
to nuclear incidents at fixed facilities. Under thisplan the Council is responsible for overall coordination of emergency planning and operational
response to a nuclear incident. The plan assigns
the following specific responsibilities for nuclear incidents to the Council.

1. Issuance of planning guidance.
2. Coordination of State response to nuclear incidents.
3. Maintaining an
emergency communications
facility.

4. Operating the State Emergency Operations
Center.
5. Emergency public information.
6. Notification of Federal authorities.
7. Coordination of State agencies and departments.

ficer. Because the watch officer could not contact
York County, he requested the Lancaster County
EMA to make that notification. At 7:25 a.m., when
he arrived at the office, the Director of PEMA wasnotified of the event.

A similar, though more detailed, plan for response
to incidents at fixed nuclear facilities was developedby BRP in September 1977. This plan establishes
PEMA as the State agency to receive notification of
an incident from the facility and to transmit this information immediately to BRP. The BRP plan also
acknowledges PEMA's responsibility for the followi ng:

Description of Response

1. Notifying the Governor, Lieutenant Governor,
State agencies and departments, neighboring
States, and Federal agencies of an emergency.
2. Relaying pertinent emergency information and instructions to appropriate counties.
3. Exercising general direction and control overState, county, and local emergency operations.
4. Coordinating assistance provided by Federal
agencies and private relief organizations.

Since the accident at TMI, PEMA, with concurrence of the Council, has taken steps to reassume planning responsibility for fixed nuclear facilities. This is in accordance with the Emergency
Management Services Code of 1978, and will
necessitate a revision (already underway) of Annex
E to the Commonwealth Disaster Operations Plan.
The plan's most recent draft is dated July 1979.
PEMA has a staff of 67, about equally divided
between professional and clerical personnel. The
professional staff is not trained in the area ofreactor-oriented radiological processes, monitoring,and dose assessment. PEMA is made up of aheadquarters staff and three area headquarters inCentral, Eastern, and Western Pennsylvania. Eacharea covers about a third of the State. PEMA also
has a stockpile of equipment at Fort Indiantown
Gap, Pa., and a maintenance repair shop for radiation monitoring equipment scattered throughout theState. The radiation monitoring equipment is for use
during enemy attack.
I nitiation of Involvement

At 7:02 a.m. on March 28, the PEMA watch officer received a telephone call at home from a utility
employee, who told him that there had been an incident at TMI-2 and that BRP should contact the facility. The PEMA watch officer immediately notified
the BRP duty officer at home. During the next halfhour, Dauphin and Lancaster Counties and thePEMA area offices were notified by the watch of-Throughout the first 2 days of the accident,
PEMA's function was principally one of notifying andupdating State agencies and county coordinators on
the status of events at TMI. However, because little
was known about the reactor status for the first 2
days, and because the radiation releases stayed ata relatively low level during this period, the BRP assessments given to PEMA on almost an hourly basis
uniformly reported "no change." Either the Director
or his representative attended most TMI-relatedpress conferences and meetings held by the Governor and Lieutenant Governor.
On Friday morning, March 30, as a result of arelease of radiation reported by the utility and arecommendation from the NRC for a 10-mile evacuation, PEMA advised the counties within 10 miles of
TMI to begin planning for an evacuation. There issome disagreement as to which counties were advised to begin 10-mile planning on Friday. The
PEMA log indicates that four counties-Dauphin,
Lancaster, York, and Cumberland-were notified at
10:15 a.m. Friday. However, only Dauphin andCumberland Counties reported that they had beenadvised at any time on Friday; Lancaster, York, andLebanon Counties (the latter having only a small
area inside the 10-mile radius) reported that they
were not notified on Friday of the need for 10-mileplans.
Following a Friday evening briefing by Harold
Denton in the Governor's office (at which Denton
mentioned that planning for a 20-mile evacuation
would be prudent), PEMA advised the counties
within 20 miles of TMI to begin evacuation planning.
From this time on, PEMA's primary function became
coordination of the counties' evacuation planning.
Although PEMA supposedly retained its responsibility for communicating with the counties and Stateagencies, PEMA had been told by the Governor's
office that the Governor desired to be the main
source of information to the media, and that such information should not be given to the counties in advance of or even simultaneously with the Governor's
statements.
At about 11:00 a.m. on Friday morning, PEMA activated its Emergency Operations Center, to which
designated State agencies sent representatives tocoordinate with PEMA. The center was to provide

1196

rapid interagency communications for decisionmaking. Because telephone lines were overloaded andl ong delays in communications were occurring,
PEMA distributed about 85 hand-held portable radios to various State agencies. PEMA also activated its emergency communications van, which is able
to link the 40 public safety and statewide radio systems in use throughout Pennsylvania. By Sunday, inan effort to improve communications with the counties, PEMA had "hot line" telephones installed in thesix counties within 20 miles of TMI.
To assist the counties in preparing 20-mile plans,
PEMA assigned a representative to each of the six
affected counties on March 31. PEMA also assigned
a headquarters staff member to review and coordinate the county plans and to assure that the Statesupport agencies knew what their responsibilities
would be.
One of the major functions performed by PEMAin this regard was coordination of the evacuationroutes that would be used by the counties. On
March 31, PEMA prepared and distributed a list ofsuggested evacuation routes.
The counties adapted these suggestions accordi ng to their individual needs and desires. In deciding
upon their final routes, the counties were assistedby the State Police, the Pennsylvania Department ofTransportation, and National Guard representatives
assigned to each county. PEMA worked throughthese representatives to assure that the final evacuation routes chosen by a county did not conflict withother counties' plans. On April 4, PEMA distributed
a map showing the final evacuation routes for eachcounty. The major purpose of this map was to indicate to traffic control agencies, such as the State
Police, what traffic density to expect along specificroutes.
The map was also used by the Pennsylvania
Department of Transportation to evaluate traffic
movement during an evacuation to estimate evacuation times. Based on this evaluation, the Department of Transportation estimated that a 10-mile evacuation would require 7 hours and a 20-mile evacuation would require 10 hours.
PEMA also served as the primary contact within
the Commonwealth for the FDAA and DCPA
representatives dispatched to the TMI area by theWhite House.
4. THE GOVERNOR'S OFFICEAs chief executive officer of the State, the Governor bears the responsibility and the authority to leadi n times of domestic crisis. In Pennsylvania, theGovernor's responsibility was clearly stated in the1197

Pennsylvania Emergency Management Services
Code in effect on March 28, 1979. This statutorycode assigned the Governor ultimate responsibility"for meeting the dangers to this Commonwealth andpeople presented by disasters." The code also established the successor to the State Council on Civil
Defense, the Pennsylvania Emergency Management
Council, made up of 16 high ranking State officials,
including the Governor and Lieutenant Governor.
The code assigned policy and direction responsibility to the Council for statewide civil defense anddisaster programs and response capabilities.
Governor Thornburgh had designated Lt. Governor
Scranton as Chairman of the Council prior to theaccident at TMI.
I nitiation of Involvement

Governor Thornburgh was notified of the accident at TMI by Oran Henderson, the Director of
PEMA, at about 7:45 a.m. on March 28, 1979.
Governor Thornburgh instructed Henderson to workthrough Lt. Governor Scranton. Henderson had
tried to notify Scranton before he called Thornburgh, but Scranton was enroute from his home tohis office. Henderson informed Scranton of the accident upon Scranton's arrival in his office at about
8:20 a.m.
Description of Response

Throughout the first 2 days of the accident, theGovernor's office functioned as contemplated bystatewide emergency plans. The Lieutenant Governor, in his role as Chairman of the Council, served
as senior State official handling TMI and spokesman
for the State. In this role on Wednesday the Lieutenant Governor held three press conferences, metwith senior Met Ed officials during the afternoon andwith NRC and DOE representatives that evening,and continuously kept the Governor abreast of thesituation. On Thursday Lt. Governor Scranton visited the site to make a personal assessment of thesituation. Governor Thornburgh's first public statement regarding TMI came during a 10:20 p.m. press
conference on Thursday evening.
Within the Governor's office a group of senior
State officials assembled to consider the course of
the accident, to advise Governor Thornburgh, and toevaluate the information being received by the office. On Wednesday and Thursday this group consisted of Jay Waldman, the Governor's Executive
Assistant, Paul Critchlow, the Governor's Press
Secretary, and Jim Seif, Special Assistant to theGovernor, as well as the Lieutenant Governor.

Depending on the issue being discussed, otherState officials, including Gordon MacLeod, Secretary of Health, Clifford Jones, Secretary of Environmental Resources, and Penrose Hallowell, Secretaryof Agriculture, were also present. Oran Henderson,
Director of PEMA, was present at many of themeetings held through Sunday, April I. Governor
Thornburgh added Robert Wilburn, Secretary of
Budget and Administration, to this group of advisors
on Saturday, March 31.
On Thursday evening the Governor's office became involved in authorizing Met Ed to resume
dumping industrial wastewater containing small
amounts of xenon from TMI into the SusquehannaRiver. Poor communication between NRC and theState and confusion within the Governor's officeover the State's authority to resume the dumping,which had been stopped by NRC officials in Bethesda, Md., delayed the NRC's authorization for Met Ed
to resume dumping. After extended discussions
among Thornburgh, Paul Critchlow, Thornburgh's
Press Secretary, and Karl Abraham, the NRC's Region I Public Information Officer, Thornburgh determined that he probably did not have authority topermit Met Ed to resume dumping.
Negotiation between Critchlow and Abraham on
Thursday night over whether the NRC or the Governor should issue a press release announcing that
Met Ed could resume dumping resulted in a stalemate not resolved until near midnight on Friday,
when Secretary of Environmental Resources Clifford
Jones issued a press statement announcing that the
NRC and Met Ed had informed the State of the needto dump the water and that DER had "reluctantly
agreed" to allow them to proceed.
During Wednesday and Thursday, the moodwithin the Governor's office was changing. Initially,
Lt. Governor Scranton relied heavily on NRC onsite
officials and Met Ed officials for information about
the plant. However, because of conflicting andoverly optimistic reports coming from both the NRC
and Met Ed, Thornburgh and Scranton began tolose confidence in the information the State was receiving from these sources. The Governor has stated that on Thursday evening he went to bed "fairly
troubled about where we were going to look todetermine precisely what was the situation at thereactor."On Friday morning, March 30, the situation in the
Governor's office took a marked change. From thatpoint on the Governor was clearly in charge of theState response to the accident. The Governor
chose not to act immediately on the NRC's evacuation recommendation that morning. He chose instead to confirm the basis of the recommendationand the source of the radiation, steps that were nottaken by the NRC personnel in the Bethesda Incident Response Center before they made therecommendation. The Governor called Chairman
Joseph Hendrie to find out what the situation wasand found that the Commission did not support therecommendation, which came from an NRC staff
member. It was during this conversation that theGovernor expressed the desire to have a central
source of information on which he could rely. As aresult of this request and subsequent conversations
between the President and Chairman Hendrie and
the President and the Governor, Harold Denton was
sent to the site Friday afternoon as the President's
personal representative to serve as the single
Federal Government source of information ontechnical issues. Denton also served as theGovernor's principal source of information on thestatus of the plant.
On Friday Governor Thornburgh also decided
that he would be the single spokesman within theState on all TMI-related matters. This decision wascommunicated to the PEMA Public Information Officer and the Director of BRP by the Governor's
Press Secretary that day. From Friday on, theGovernor's Office was the focal point for all information coming into or going out of the State.
Throughout the course of the accident theGovernor was faced with decisions on protecting
the health and safety of the people of Pennsylvania.
The Governor has stated that he thought immediately of evacuation on the morning of March 28,
when he was notified of the incident, and that it wascontinuously on his mind for the next 10 days. In
evaluating the need for evacuation, he weighed thepossible risks from the TMI plant against the provenhazards of moving people under panic conditions.
He has stated that he would not have hesitated toorder an evacuation if it appeared to be the safest
course of events, but could not, in good conscience,
have ordered it based on the facts at his disposal.
Based on the situation at the plant and advice
from Chairman Hendrie and the Governor's top staff,
the Governor did advise certain protective actions:
On Friday, March 30, he issued an advisory for
those within 10 miles of TMI to stay indoors, an advisory for pregnant women and preschool children
to leave the 5-mile area, and an order to closeschools in the area around TMI in recognition of thepossibility of a general evacuation, as well as tokeep school-age children of families with pregnant
women or preschool-age children with their families.
Governor Thornburgh's principal source of information on plant status was Harold Denton. Denton
briefed Governor Thornburgh each day; each brief-

1198

i ng was followed by a joint press conference. All information on PEMA operations came into theGovernor's office through Lt. Governor Scranton, information on radiation monitoring was coming
through Secretary of Environmental Resources
Jones, and information on possible contamination ofmilk and water came through Secretary of Agriculture Hallowell.
On Friday, March 30, Governor Thornburgh
directed radiation and nuclear engineering experts
i n BRP to go to the site to provide him with a continuing, independent technical assessment of thedanger posed by the reactor. For the next month
William Dornsife, a BRP nuclear engineer, spent 12hours a day on site, independently verifying technical information for the Governor's office.
On Friday afternoon at about 2:00 p.m., Lt.
Governor Scranton convened a meeting of thePennsylvania Emergency Management Council.
During the 40-minute meeting Scranton briefed
those present on his understanding of the accident,
each Council member reported on the involvementof his agency, and Henderson, the Director of
PEMA, indicated what support he expected fromeach State agency. At least part of the reason that
this meeting was called appears to have been therequirement in section 7312(d) of the Pennsylvania
Emergency Management Services Code, that if a
disaster is determined actually or likely to exist, theChairman of the Council shall within 48 hours callthe Council into emergency session. Although weare unaware that such a determination was officiallymade, the escalation of events that morning could
have led the Governor or Lieutenant Governor tobelieve that a disaster situation was likely.
On Saturday, March 31, the Governor directed
Robert Wilbum, Secretary of Budget and Administration, to review the emergency plans in existence
and those being developed to independently determine how much confidence could be placed in them.
This review was carried out throughout the weekend. By Saturday night, Wilburn was able to assure
the Governor that a 5-mile evacuation could be carried out and that a 10-mile evacuation could be carried out with a reasonable degree of success andminimal loss from injuries or property damage.
Although review of the 20-mile evacuation plans
continued into Sunday, by Sunday afternoon the
Governor's office had concluded that there was little
use in planning for a 20-mile evacuation since there
were no plausible scenarios in which a 20-mile evacuation would be required. This decision wasreached on the basis of information from Harold
Denton and Dr. Niel Wald, a consultant to the State.
It was confirmed Sunday evening by Chairman Hen-drie when he met with Governor Thornburgh. Attention within the Governor's office then focused on
the 5- and 10-mile plans for evacuation, always
recognizing, however, that the consequences of anevacuation order could extend to 20 miles.
A major decision confronting Governor Thornburgh throughout the accident was whether to request the President to declare a disaster under theDisaster Relief Act of 1974, which would commit
Federal resources to supplement State operations.
According to Thornburgh, Waldman spoke to Watson of the White House on Friday afternoon and
was assured that Pennsylvania would receive thesame level of Federal assistance, both during andafter the incident, without a disaster declaration, as
it would if a disaster was declared. In addition, bothThornburgh and Watson were concerned that thedeclaration of a disaster would unnecessarily escalate the concerns of the populace over the accident. As a result, a disaster declaration was neverrequested by the Governor.
Paperwork was
prepared, however, to enable the Governor to request a declaration immediately if there was achange in plant status or if it was required in orderto improve Federal response.
The extensive role played by the Governor's office in responding to the accident at TMI is primarily
attributable to the extended nature of the accident.
Had the accident progressed more rapidly-overhours rather than days-as accidents at reactors
had been expected to, there would have been notime for extensive involvement by the Governor's
office and the need for protective actions would
have been quickly and abundantly clear.
5. PENNSYLVANIA DEPARTMENT OFAGRICULTURE
The head of the Pennsylvania Department ofAgriculture is one of the 16 members of thePennsylvania Emergency Management Council discussed above.
Historically, responsibility for State planning fori ncidents at fixed nuclear facilities was vested in
BRP, part of the DER. BRP developed a plan for
managing incidents at fixed nuclear facilities in September 1977. This plan describes the following
emergency responsibilities of the Pennsylvania
Department of Agriculture.
1. To serve as liaison with the agricultural community.
2. To provide, at the recommendation of BRP, forthe protection of the supply of milk and otherfoodstuffs, livestock, and field crops.

1199

However, the Bureau of Forestry has no designatedfunctions in emergency response actions.
The bureau had been aware of the TMI accident
through media reports, but it did not become activel y involved until Saturday, March 31, when it furnished two trucks and two cars, with radios, for use
by EPA personnel in their radiation monitoring efforts. An additional eight vehicles with radios were
provided to EPA on April 1. Maps and important
telephone numbers were furnished to the EPA personnel, and a radio engineer from the bureau spent
about 20% of his time in support of the equipment
and EPA operations during the first month following
the accident. The vehicles logged up to 3000 milesof travel while they were on loan to EPA and, as of
mid-August, EPA was still using some of the
Bureau's equipment.

3. To provide for informing the agricultural community of the need to take protective action.
4. To provide for sampling of commodities in the affected areas.
The actions taken by the Department of Agriculture in response to TMI were consistent with those
responsibilities.
At TMI-2 a major radiological effort was directed
toward investigating, evaluating, and explaining theexposure of people and animals to radioiodine from
TMI by way of the grass-cows and goats -milk andmilk products -people pathway. The Department ofAgriculture worked closely with BRP in this effort.
At 8:15 a.m., March 28, the Department of Agriculture was notified by BRP that there was a problem at TMI. At 11:20 a.m. on March 28, BRP requested the department to obtain milk samples thatevening. The department obtained the samples
from 10 farms within a 10-mile radius of TMI. Radiological analyses of the samples by BRP showed noradioactivity above the detection level of 10 picocuries per liter. Subsequent milk samples collected by
the department showed a maximum of 21 picocuries
per liter. Vegetation samples also were collected
for BRP.
At no time did the department recommend dumpi ng milk or diverting it to a particular use; however,on Friday, March 30, the department officially issued
a recommendation that farmers get their animals indoors, put them on stored feed, and keep themaway from streams. The recommendation did not
specify to what distance from TMI these actions
should be applied, though it was issued when otherprotective actions were being discussed for thearea within 10 miles. After the recommendation had
been in effect about a month, it was rescindedthrough Agriculture's Public Information Office. The
recommendation was only a precautionary measure,
not a matter of necessity for the protection of publichealth and safety. It was taken realizing that there
was little need for pasturage at that time of year,
and that there was plenty of stored feed.
The department responded to a number of all eged cases of sickness or death of animals causedby radiation. Investigation and autopsies by Department of Agriculture veterinaries showed no case inwhich this was so.

7. PENNSYLVANIA DEPARTMENT OF HEALTH

6. BUREAU OF FORESTRYThe Bureau of Forestry is part of the Pennsylvania DER and the secretary of DER is a member of
the Pennsylvania Emergency Management Council.

1200

A primary function of the Pennsylvania Department of Health is to conduct a licensing and regulati ng program that assures the quality of health within
the Commonwealth. It also serves as the surrogate
county health department for 61 of the 67 counties
in Pennsylvania. The head of the Pennsylvania
Department of Health is one of 16 members of thePennsylvania Emergency Management Council.
BRP's plan for incidents at fixed nuclear facilities,
developed by BRP in September 1977, sets the
emergency responsibilities for the Department of
Health as assisting in the continued delivery of
emergency and routine medical care and conducting
emergency functions as directed by higher authority. Similar and more detailed responsibilities were
set out in the Commonwealth Disaster Operations
Plan of July 1977.
At 8:00 a.m., March 28, the Department of Healthwas notified by PEMA of an incident at TMI. The
Pennsylvania Department of Health's incident
response activities were principally in five areas:
the Governor's advisory that children and pregnant
women leave the area, management of potassiumi odide, liaison with the medical community, response
to concerned citizens, and followup health impact
studies.
On Friday morning, March 30, the Governor advised that pregnant women and preschool children
within 5 miles of TMI leave the area. This recommendation was consistent with the Department of
Health's recommendation to the Governor earlier
Friday morning that there should be an evacuationof children under the age of 2 and pregnant women.
The Department's recommendation took into account the particular radiation sensitivity of the fetus

and the young child and the apparent uncertainty
about further developments at TMI.
The Department of Health had a major role in thedecision not to distribute and administer potassium
iodide to the public. Potassium iodide is a prophylactic drug that is used to block the uptake of radioactive iodine by the thyroid. During the response
to TMI, the Federal Department of Health, Education,and Welfare arranged for manufacture and shipment
to Pennsylvania of 250 000 bottles of potassiumi odide and recommended its use. The Pennsylvania
Department of Health assumed responsibility for the
drug and prepared for its distribution, but it did not
authorize its use. In view of improving conditions at
TMI, the department decided not to distribute it to
the public.
The department served as a source of information for the Pennsylvania medical community,
responded to requests from the public for information on TMI-related health effects, and now has alead role in an HEW program to determine thehealth effects of the accident.
8. PENNSYLVANIA INSURANCE DEPARTMENT
The Pennsylvania Insurance Department has no
representative on the Pennsylvania Emergency
Management Council. However, it still has the
responsibility for providing PEMA with such property
damage information and data as may be available
through insurance industry channels. Of course,
this function was not necessary for TMI.
The insurance department was aware of the TMI
accident from media reports starting on March 28,
1979. However, the department did not become involved in the response efforts until Sunday, April 1,
when
department
representatives
metwithrepresentatives of the nuclear insurers. The department representatives helped arrange working facilities for the nuclear insurers' representatives and,during the following days, worked with the insurers'
representatives to smooth relations with the public.
The department has monitored the claims payments
to the evacuees.
9. PENNSYLVANIA DEPARTMENT OF JUSTICE
The Attorney General is a member of thePennsylvania Emergency Management Council. The
Department of Justice provides legal advice to theGovernor, to the Lieutenant Governor, to PEMA, andto disaster victims. It is responsible for furnishing
PEMA with information regarding disaster damage
to and problems faced at criminal institutions andfacilities. The Department of Justice is also charged

with taking specific actions designed to assure effective consumer protection.
The Department of Justice was notified of theTMI-2 accident on Wednesday, March 28, by PEMA
shortly after PEMA was notified by the plant. Laterthat day, Department of Justice personnel began
researching applicable State statutes and drafting
executive orders that would have been required by
the Governor had he chosen to declare a disasterand direct an evacuation. The Department is now
actively involved in various legal actions that were
i nitiated as a result of the TMI accident; it seeks torepresent the interests of the citizens of Pennsylvania.
10. PENNSYLVANIA DEPARTMENT OFMILITARY AFFAIRSThe Pennsylvania Department of Military Affairs isdirected by the Adjutant General, who is a memberof the Pennsylvania Emergency Management Council. The Adjutant General commands the Pennsylvania National Guard (PNG). The designated function of the PNG is to provide assistance, as directedby the Governor or requested by PEMA, and in accordance with the "State Plan for Military Support ofCivil Defense," in emergency protection measures,
rescue, evacuation, medical and mass care, maintenance of law and order, air and ground transport,
debris removal, facility repair, and other basic andessential disaster relief operations.
The Adjutant General was notified of the TMI-2
accident by PEMA early Wednesday morning,
March 28. At the request of PEMA, the PNG started
to prepare a list of transportation facilities that could
be used in support of an evacuation. However, laterthat morning PEMA advised that conditions at theplant had improved and that planning for PNG involvement could be discontinued.
On Friday, March 30, PNG again became involved after notification of the radiation release at
the TMI plant. Selected PNG officers were called toState active duty. An operation plan was preparedand issued on March 31; it provided for use of PNG
personnel to assist civilian authorities in evacuationof residents, traffic control, sealing off evacuatedareas, and provision of local security. Five PNG
battalions and a headquarters unit were placed onalert, but were never called to active duty.
In addition to planning for the mass evacuation,
the PNG provided six GP medium tents for use as
shelters for emergency workers at the plant site;
cots, blankets, and pillows for use at the Hershey
Arena mass care center and at the PEMA Emergency Operations Center; helicopter transportation ofwater samples from the TMI plant to State College,1201

Pa., for analysis; office space for the NRC in the Air
National Guard office building at the Harrisburg
I nternational Airport; ground support services fortransient aircraft hauling passengers and cargo insupport of the emergency efforts at TMI; and a radio
communications net linking the PNG headquarters
with PNG elements at the county emergency operations centers.
PNG's active duty service was terminated on
April 5, 1979. The overall cost for the PNG efforts
was nearly $12 000.
11. PENNSYLVANIA STATE POLICEThe Commissioner of the Pennsylvania State Poli ce (PSP) is a member of the Pennsylvania Emergency Management Council. The State Police has anumber of designated functions in support of Stateemergency response actions. These include providing information concerning significant disaster
effects and problems, collecting and maintaining
records of dead and missing persons, assisting
emergency dissemination of essential disaster information and instructions, and assisting in State,county, and local emergency operations.
The State Police were first notified of the TMI-2
accident by a telephone call from the plant at 7:14
a.m. on Wednesday morning, March 28. Several
PSP officers were immediately dispatched to thesite for traffic control. A PSP helicopter was furnished to fly radiation monitoring teams conducting
radiation surveys to the survey locations. The PSPcontinued to provide traffic control and security inthe plant area on March 29. On March 30, following
news of the radiation release, the PSP installed aportable radio base station at the TMI observation
center to provide a radio link to the PEMA operations center in Harrisburg. A mobile command post
was set up near the observation center later thatafternoon. Increased patrolling was conducted thatevening to prevent looting of evacuated dwellings.
The PSP became actively involved in the evacuation planning on Saturday, March 31. The PSP
worked closely with the counties at risk to coordinate evacuation routes, in conjunction with PEMA,
the State Department of Transportation, and National Guard personnel. They were concerned also withtraffic control and security in the designated hostcounties. In the event the evacuation had been ordered, the first priority of the PSP would have been
traffic control; security would have been a second ary goal. During the days following the accident, amajor activity of the PSP was escorting special
vehicles that were hauling equipment to the site. A
total of 4705 hours were devoted to the TMI-2
response effort from March 28 to April 11, 1979.

12. PENNSYLVANIA DEPARTMENT OF
TRANSPORTATIONThe Secretary of the Pennsylvania Department ofTransportation (PennDOT) is a member of thePennsylvania Emergency Management Council.
PennDOT has a number of specific functions inemergency response actions. These principally
i nvolve providing information to PEMA regarding
assistance in supply of motor fuel and transport
services, technical and administrative assistance inroad repair, and disruptions of road, rail, and airtransportation.
PennDOT was advised of the TMI-2 accident
shortly after PEMA was notified by the plant on
Wednesday, March 28. The hot line to the PEMA
Emergency Operations Center was immediately activated, but no special actions were taken until Friday, March 30, following notification of the radioactive release at the TMI plant. At that time PennDOT
activated its Emergency Response Team and wenti nto 24-hour operation. During the following days,
PennDOT personnel arranged for transportation in
support of county evacuation plans and worked
closely with the counties and the State Police tocoordinate county plans for traffic flow and with the
National Guard to support the planned evacuation
efforts. Coordinated evacuation plan maps wereprepared by PennDOT and issued through PEMA.
13. PENNSYLVANIA TURNPIKE COMMISSION

The Pennsylvania Turnpike Commission has been
assigned responsibilities in the area of emergency
operations. These responsibilities include arranging
for toll-free travel of emergency vehicles along the
turnpike, assistance in the emergency transport ofpersonnel and materials to points on or in the immediate vicinity of the turnpike, and assistance inemergency communications to points on or in thei mmediate vicinity of the turnpike.
The role of the turnpike commission in responseto the TMI-2 accident was limited to cooperation
with PEMA and the State Police in planning for useof the turnpike during a general evacuation. This
planning occurred essentially during March 31
through April 2.
14. BORDERING STATESThe accident at TMI-2 caused extensive radiological monitoring efforts by government agencies inStates adjacent to Pennsylvania: Ohio, New York,New Jersey, Maryland. These efforts were aimed atdetermining the extent of TMI-related radiation hazards in the respective States in order to decidewhat, if any, actions should be taken to protect theircitizens. The determinations of the extent of radia-

1202

Lion hazards also enabled authoritative responses tocitizens about the levels of radiation in their States.
Notification of radiological personnel in four of theneighboring States took place at 9:00 or 10:00 a.m.
on Wednesday, March 28. Ohio first learned of thei ncident from the news media; New York was notified by its regional office of DCPA, which had heardof it on a news broadcast; Maryland was informed
by a person regulated for the use of radioactive material by Maryland; New Jersey was informed by the
NRC. None of these States were first informed of
the incident by Pennsylvania State personnel.
New York, New Jersey, Maryland, and Ohio haveongoing State radiation programs that are conducted by experienced personnel. Upon notification of
the TMI incident, those groups took action to evaluate the radiation levels that might result in theirrespective States and to evaluate the possibility that
contaminated water and milk might enter their
States.
Milk received particular attention because New
York, New Jersey, and Maryland obtain milk fromdairies in the TMI area. By 2:00 p.m. on March 28,
the Maryland strategy for sampling milk had been
established. The strategy called for monitoring milk
at farms in Maryland and at selected farms in
Pennsylvania that have Maryland-issued permits toship milk to Maryland. The decision to concentrateon milk sampling at the farm level was based on thereasoning that if any contaminated milk was found,restrictions on its distribution and use could moreeasily be applied at that level than at other places in
the normal distribution channels. Sampling of milk
at the retail level was done secondarily.
Maryland obtained samples from the March 29
morning milking. Some samples came from farms
as close to TMI as 3 miles. Milk was sampled by
Maryland for 2 weeks, although the program was
modified during the final 2 days to sample milk frombulk tanks when the milk was delivered to dairies.
Maryland obtained and analyzed a total of 123 raw
milk samples for possible TMI-related radioactivity.
New Jersey analyzed about 120 milk samples.
New Jersey identified approximately six processorsthat obtained milk from within a 50-mile radius of
TMI. Raw milk samples were obtained from milk
trucks as they arrived at the processors' plants in
New Jersey.
New York collected and analyzed milk samples
from both Pennsylvania and New York suppliers.
About half a dozen Pennsylvania suppliers of milk to
New York were identified. The identification of milk
suppliers was somewhat complicated by an ongoingmilk strike in New York that disrupted normal
sources of supply.
Ohio did no special milk analyses, because Ohio
was predominately upwind of TMI, the Ohio-

1203

Pennsylvania border is about 200 miles from TMI,
and other groups sampling milk from the TMI area
had reported no significant contamination. Milk
sampling by Maryland, New Jersey, and New Yorkrevealed no iodine (the suspected radioisotope)
above the minimum detectable limit of 10-20 pCi/I.
On Wednesday, March 28, Maryland began taki ng grab samples of the Susquehanna River and on
Friday began composite sampling to evaluate theextent of TMI-caused radioactivity in the river because a number of Maryland municipalities draw
drinking water from that source. Maryland collected
and analyzed a total of 85 water samples. The only
evidence of radioactivity above normal levels in theSusquehanna water samples taken by Maryland
1 33
Xe found in several
was a low level of dissolved
samples collected at the Holtwood Dam sampling
site, about 35 miles downstream of TMI.
Delaware River water was sampled at the intake
to the Trenton filtration plant and analyzed by New
Jersey. Because the Delaware River does not flow
past TMI, any TMI-generated radioactivity that might
have been detected would have been airborne andthen deposited in the watershed for the Delaware
River. At no time in its radiation monitoring did New
Jersey detect any radioactivity attributable to TMI.
Both New Jersey and Maryland used helicopterswhen surveying their respective Pennsylvania borders and detected no radiation attributable to TMI.
New Jersey, Maryland, and New York collected
and analyzed air samples. New Jersey found no
TMI radioactivity. Maryland found no unusual radioactivity until a sample counted early 131l;
Sunday night133
Xe andthese levi ndicated very low levels of
els were 1000 and 90 femtocuries per cubic meter
respectively. With one exception, New York air
sample results showed no TMI-generated radioactivity. That exception was the detection in Albany ofvery low levels of xenon.
External radiation level measurements weremade by New Jersey and Maryland. Maryland also
sampled fish from the Susquehanna River and oysters from the Chesapeake Bay. No radiation levels
or radioactivity above normal background wasfound.
Maryland, New Jersey and New York used theresults of their radiation measurements in determini ng that they need not implement any protective actions. The results were also used in responding tonumerous questions by concerned citizens.
Maryland was prepared to assist Pennsylvania inhandling hospitalized persons if an evacuation of 10
to 20 miles from TMI had been implemented. It
developed plans for the use of Maryland ambul ances to move critically ill persons from thePennsylvania hospitals to designated Maryland hospitals.

APPENDIX 111.8

DETAILED CHRONOLOGY OF
EMERGENCY RESPONSE

3/28/79
4:00 a.m.
6:55 a.m.
7:02 a.m.

7:04 a.m.
7:05 am.
7:08 a.m.

7:09 a.m.
Accident inflation.
Site Emergency declared by shift
supervisor based on alarms of process and area radiation monitors.
Pennsylvania Emergency Management Agency (PEMA) duty officer
notified of Site Emergency by shift
supervisor, who requested that
PEMA notify the Bureau of Radiation Protection (BRP).
Plant attempts notification of NRC
Region I. Answering service receives the call.
BRP duty officer notified of Site
Emergency by PEMA duty officer.
Dauphin County Office of Emergency Preparedness notified of Site
Emergency by PEMA duty officer.

7:09 a.m.
7:10 a.m.
7:12 a.m.

7:14 a.m.
7:20 am.
1204

Department of Energy (DOE) Radiological
Assistance
Program(RAP) office at Brookhaven National
Laboratory notified of Site Emergency by plant.
Dauphin County notified of Site Emergency by plant.
PEMA duty officer attempts to notify York County Emergency Operations Center of Site Emergency.
LancasterCountyEmergency
Management Agency notified ofSite Emergency by PEMA duty offi cer,
who requests Lancaster
County to notify York County.
Pennsylvania State Police (PSP),
Troop H, notified of Site Emergency
by plant.
PSP dispatches several traffic control officers to the site.

7:24 am.

General Emergency declared by
TMI station manager based onreactor building dome radiation
monitor reading greater than 8 R/h.
7:25 a.m.
BRP calls TMI-2 control room toconfirm earlier notification from
PEMA. BRP informed of escalation
to General Emergency. Telephoneli ne between BRP and control room
held open.
7:30 am.
Dauphin County notified of escalation to General Emergency byplant.
7:35 a.m.
DOE RAP office notified of escalation to General Emergency byplant.
PEMA notified of escalation to Gen7:35 a.m.
eral Emergency by plant.
7:36 am.
PEMA begins notifying BRP and
Dauphin, York, and Lancaster
Counties of escalation to General
Emergency.
7:37 a.m.
Reading, Pa., office of utility
attempts to notify NRC Region I.
Answering service receives the call.
7:40 a.m.
Plant attempts to notify NRC
RegionI.
Answering
servicereceives the call.
7:40 a.m.
Plant sends radiation monitoring
teams to west shore of Three MileI sland and to Goldsboro.
Henderson of PEMA notifies Gover7:45 am.
nor of plant status.
7:45 a.m.
NRC Region I switchboard opens.
BRP notifies PEMA that there is a
7:45 a.m.
calculated offsite release of 10 R/h
i n the direction of Brunner Island
and Goldsboro and that preparations should be made for possible
evacuation.
NRC Region I calls TMI-2 control
7:50 a.m.
room and learns of the accident.
PEMA notifies York County of pos7:52 a.m.
sible need to evacuate BrunnerIsland and Goldsboro.
membersof
7:55-8:15 a.m. PEMA
notifies
Pennsylvania Emergency Management Council of accident at TMI.
NRC Region I activates its Incident
8:00 am.
Response Center and notifies NRC
Headquarters of accident.
NRC
Headquarters
activates
8:05 a.m.
Incident Response Center (IRC).
8:05-9:00 am. NRC Headquarters personnel notified of accident.
1205

8:15 a.m.

BRP advises PEMA that based onl atest information, evacuation alertsof Brunner Island and Goldsboro
should be cancelled.

PEMA calls York County to pass on
i nformation received from BRP and
to advise that alerts could be cancelled.
Lieutenant Governor notified of
8:20 a.m.
i ncident by Henderson of PEMA.
First team of five inspectors leaves
8:40 a.m.
NRC Region I for the site.
Defense Civil Preparedness Agency
8:45 a.m.
(DCPA) Region Two Center notifiedof General Emergency by PEMA.
Brookhaven Area Office notifies
8:45 a.m.
Emergency
DOE
Headquarters
Operations Center (EOC) of theaccident.
DOE/EOC calls NRC/IRC to verify
8:55 a.m.
i nformation regarding accident.
DCPA Region Two Center notifies
9:00 a.m.
of
the
DCPA
Headquarters
accident.
9:00 a.m.
NRC Region I contacts Brookhaven
RAP office and confirms that two
RAP teams are on standby.
9:00 a.m.
Second team of inspectors leaves
NRC Region I for TMI
9:00 a.m.
Commissioner Gilinsky notifies J.
Mathews at White House of incident.
9:00-9:30 a.m. NRC/IRC notifies White House
Roomof
accident.
Situation
Appropriate House and Senate
staffs notified of accident by NRC
Office of Congressional Affairs.
9:02 a.m.
Environmental Protection Agency(EPA) notified of accident by
NRC/IRC.
9:02 a.m.
Associated Press releases nationalbulletin advising that a General
Emergency has been declared at
the plant but that no radiation had
been released. Details not yet
available.
9:27 a.m.
DCPA contacts NRC/IRC to verify
i nformation regarding the accident.
9:30 am.
Plant starts dumping heat throughatmospheric dump valves.
10:00 a.m.
DOE/EOC places Aerial Measurement System/Nuclear Emergency
Search Team (AMS/NEST) at
Andrews Air Force Base on
standby alert.
8:20 a.m.

10:05 a.m.
10:17 a.m.
10:20 a.m.
10:30 a.m.

10:30 a.m.

11:00 a.m.
11:00 a.m.
11:00 est.
11:04 a.m.
11:10 a.m.
11:18 a.m.
1:15 p.m.

1:30 p.m.
2:30 p.m.
4:30 p.m.

5:00 p.m.

10:00 p.m.

Region I response team arrives on
site.
Controlroom
personnel
donrespirators.
Monitoring teams begin detecting
i ncreased radiation levels on site.
NRC
press
releaseconfirms
incident; release of primary water
to containment; no offsite radioactivity detected.
National Military Command Center(NMCC) and Joint Nuclear Accident
Coordinating Center (JNACC) notified of accident by DOE/EOC.
NRC/IRC contacts DOE/EOC andrequests movement of AMS/NEST
to Capital City Airport.
Second NRC Region I response
team arrives on site.
State requests shutdown of auxiliary building ventilation system.
Auxiliary building ventilation systemshut down.
Nonessential personnel evacuatedfrom site.
State BRP contacts Brookhaven
RAP office and requests assistanceof a RAP team.
Herbein press conference reports
no significant levels of radiation;
reactor being cooled in accordancewith design; no danger of core
meltdown.
AMS/NEST unit arrives at Capital
City Airport.
Brookhaven RAP team arrives atCapital City Airport.
Lieutenant Governor press conference. Situation more complex thanState led to believe; still taking
tests; no danger to public health;
Met Ed had given misleading information;
radiation
had
been
released; levels decreasing during
afternoon.
Second NRC press release. Maximum offsite activity 3 mR/h; ECCS
functioning; reactor shut down;
system pressure being reduced.
Lieutenant Governor press conference. No current radioactive leakage from containment; atmosphericactivity result of auxiliary building
ventilation; high radiation levels onsite; no critical levels off site.

3/29/79
12:15 a.m.
2:00 a.m.

12:45 p.m.
3:45 p.m.
4:00 p.m.
5:15 p.m.

10:00 p.m.
3/30/79

7:10 a.m.
7:44 a.m.
8:01 a.m.

8:40 a.m.
8:42 a.m.
8:45 a.m.
9:00 a.m.

9:15 a.m.

9:18 a.m.
9:25 a.m.
9:30 a.m.

1206

Third NRC press release. Pressure
and temperature still dropping;water released to auxiliary building.
Additional
RAP
team
from
Brookhavenarrives
early.
AMS/NEST unit arrives from Las
Vegas.
Lt. Governor Scranton visits site.
Lieutenant Governor briefs Governor on visit.
RAP teams from Pittsburgh Naval
Reactors(Bettis)replace
Brookhaven RAP teams.
Governor holds press conference.
No cause for alarm; no danger topublic health; no reason to disrupt
daily routines; situation appears
under control, but important toremain alert and informed.
Higgins informs Critchlow of possibility of extensive fuel damage.

Venting of makeup tanks initiated.
Helicopter dispatched to monitor
radiation release.
Helicopter measures dose rate of1200 mR/h over Unit 2 auxiliarybuilding vent stack.
PEMA notified by plant of 1200
mR/h release.
BRP and Governor's office notified
by plant of radiation release.
NRC/IRC notified of 1200 mR/hrelease.
Mathews of the White Houseadvised of a wire service notification of the 1200 mR/h release.
Confirmed almost simultaneously
by telephone call to Mathews from
Commissioner Gilinsky.
Collins of NRC calls Henderson of
PEMA to recommended evacuationout to 10 miles downwind fromplant.
Gallina of NRC at TMI calls NRC
Region I and NRC/IRC to recommend against evacuation.
BRP calls Collins to state that BRP
does not recommend evacuation.
Gallina recommends to Governor's
office not to evacuate.

9:50 a.m.

9:55 est.
9:59 a.m.

10:15 a.m.

10:25 a.m.

10:47 a.m.
11:00 a.m.
11:15 a.m.

11:40 a.m.

12:00 noon
12:30 p.m.

12:40 p.m.

1:15 p.m.
1:30 p.m.

Henderson calls Collins. Informedthat NRC/EMT was still recomHenderson
mending evacuation.
reports that BRP recommended to
the Governor not to evacuate.
NRC Commissioners decide evacuation unnecessary.
Governor calls Chairman Hendrie.
Governorinformed
evacuation
unnecessary, but advisable to havepersons within 5 miles downwind of
the plant stay indoors.
PEMA directs Dauphin, York, Lancaster, and Cumberland Counties
to start planning for 10-mile evacuation.
Governor makes live broadcast
over WHP radio advising people
within 10 miles of the plant to stayi ndoors with doors and windows
closed.
President Carter calls Chairman
Hendrie; Denton ordered to site.
Mathews and Odom brief Watsonand Eidenberg.
President Carter calls Governor
Thornburgh. Concurs in "no evacuation" decision, states that Denton
comingtosite aspersonal
representative.
Chairman Hendrie calls Governor.
Denton's arrival discussed; concurs
in recommended evacuation ofpregnant women and young children.
PEMA lifts "take-cover" advisory.
Governor holds press conference;
announces that while there is no
reason for panic, advisable forpregnant women and preschool
children to evacuate area within 5
miles of TMI.
Roger Mattson calls Chairman Hendrie. Hydrogen bubble estimated at1000 cubic feet at 1000 pounds per
square inch. Recommends evacuation out to 10 miles.
Mathews advises President Carterof problems with reactor, including
extensive fuel damage.
Meeting at White House attended
by NRC, DCPA, FDAA, FPA, DOE,
and DoD. Decided that McConnell(DCPA) and Adamcik (FDAA) would
go to the site.

2:00 p.m.
2:00 p.m.
3:30 p.m.

Midafternoon
3:45 p.m.

4:00 p.m.

4:05 p.m.
5:00 p.m.
5:30 p.m.
8:30 p.m.
10:00 p.m.

11:00 p.m.
11:30 p.m.
3/31/79
morning

11:00 am. est.

1207

Meeting of Pennsylvania Emergency Management Council.
Denton and staff arrive on site.
Jack Watson of the White House
calls Governor Thornburg. Tells
him that McConnell and Adamcik
coming to the site.
Direct telephone lines installed linki ng White House, Governor's office,
NRC, and site.
Chairman Hendrie calls Governor
Thornburgh. Reports on core damage and hydrogen bubble problem
and suggests that the Governor put
his emergency planning people on
alert status for 20-mile evacuation.
Close to zero chance for a hydrogen explosion in the pressure
vessel.
UPI wire quoting Dudley Thompson,
NRC, as saying there exists possibility of core meltdown within a few
days.
Denton calls Governor with prelimi nary report.
Powell White House press conference. Meltdown said to be "at thevery least speculative."
McConnell of DCPA arrives at
PEMA EOC in Harrisburg.
Denton meets with Governor torender status report.
Governor and Denton hold joint
press
conference.
Governorreports no need for general evacuation; earlier advisory regarding
pregnant women and children
remains in effect. Denton stresses
that there could be no explosion in
the reactor vessel and that thepossibility of a core meltdown isvery remote.
FDAA's Adamcik and staff arrive inHarrisburg.
PEMA starts contacting counties tobegin planning for 20-mile evacuation.
Calffano of HEW recommends 20mile evacuation to White House
unless
NRC
providesfirm
assurance that reactor coolingsafely.
Utility press conference. Crietz
announces no more Met Ed press12:00 noon

2:45 p.m.

5:00 p.m.

8:23 p.m.
8:50 p.m.

9:00 p.m.
11:00 p.m.

4/1/79conferences; NRC to act as
spokesman in future.
Herbeinannounces that hydrogen bubble issmaller and indicates that the plantis being brought under control.
Denton press conference. Denton
i ndicates crisis not over; NRC still
examining bubble size data; does
not believe bubble poses a probl em.
Hendrie press conference. Reactor
i n a stable configuration and fuelcooling down; possibility of precautionary evacuation while hydrogenproblem handled; could be someti me before there would be any
possibility of flammable condition.
Governor's
press
release.
Advisory evacuation of pregnant
women and preschool children
remains in effect; no necessity offull evacuation; no threat to publichealth in milk or drinking water.
AP editor's advisory that hydrogen
bubble becoming explosive.
AP wire story. Danger in attempti ng to remove bubble; equally risky
to do nothing; critical point within
two days.
Denton impromptu press briefing.
Hydrogenbubblewould
notbecome explosive for 9-12 days; noi mminent danger.
Governor and Denton hold jointpress conference. Governor notes
the erroneous or distorted reports
during the day regarding the plant
and asks people to listen carefully
to Denton. Denton states that
there was no possibility of a hydrogen explosion in the reactor vesselin the near term and also that heand Washington were in essential
agreement regarding the plantstatus. President Carter's upcoming visit announced.

10:45 a.m.

Hendrie and Denton brief Governor
on bubble status. The problem hadessentially gone away.
1:00-2:30 p.m. President Carter visits the site.
2:00 p.m.
Denton press conference. Core
temperatures steady; action still
1208

Midafternoon
7:00 p.m.

4/2/7911:15 a.m.

4/3/79

1:17 p.m.

2:28 p.m.
2:40 p.m.

9:30 p.m.

4/4/794/6/79

underway to eliminate hydrogen
bubble; evacuation still considered
unnecessary.
NRC convinced that there is nochance of a hydrogen explosion in
the reactor vessel.
Governor issues press release.
Advisory
regardingpregnant
women and preschool children still
i n effect; State offices to conductbusiness as usual on Monday.
Denton press conference. Fueltemperatures
still
dropping;
dramatic decrease in size of hydrogen bubble; earlier reports regardi ng possible detonation of hydrogeni nside the reactor vessel based ondata that were too conservative;
plant beginning to use hydrogen
recombiner to reduce hydrogenconcentration in containment.
Eidenberg of the White House,
i n response to questions raised by
Waldman of the Governor's Office,asks the HEW Public Health Service to prepare recommendations
regarding use of potassium iodide.
Califano of HEW sends memo to
Watson of the White House.
Attaches recommendations fromSurgeon General regarding use ofpotassium iodide.
Watson telecopies HEW recommendations to Governor.
Denton press conference. Situation at plant stable; hydrogen
explosion no longer considered a
problem.
Governor's press conference. Hydrogen bubble had dissipated, reactor core is stable; plans being
considered to bring plant to safe
shutdown.
Denton press conferences. Minor
problems noted; basically plantunder control; core cooling; radiation releases largely stopped; plans
being made for final plant shutdown.

4/9/79

Governor's press conference. Lifts
allprevious
recommendations,advisories, and directives; pregnant
women and preschool age children
could safely return home; schools
to reopen on 4/10/79; State offices
to return to business as usual;1209

4/27/79

emergency preparedness forces
shifting from full alert to on-callstatus; no residual threat to publichealth in milk or drinking water.
Plant placed on natural circulation
cooling.

APPENDIX 111.9

FEDERAL LEGISLATIVE DEVELOPMENTS
SINCE TMI

This Appendix outlines the major executive initiatives undertaken by President Carter since theaccident at Three Mile Island and the NRC appropriations bill proposed in Congress for fiscal year 1980.
ESTABLISHMENT OF FEDERAL EMERGENCY
MANAGEMENT AGENCY (FEMA)On March 31, 1979, President Carter activatedthe Federal Emergency Management Agency(FEMA), which was established under Section 304
of Reorganization Plan No. 3 of 1978. By Executive
Order 12127, he transferred to FEMA functions fromthe Department of Commerce and the Departmentof Housing and Urban Development and delegatedsome of his own powers. These functions concerned fire prevention and control, operation of theEmergency Broadcast System, flood disaster protection, and disaster insurance. On July 20, 1979,
the President signed Executive Order 12148, whichtransferred additional functions to FEMA. These

functions had been vested in the President, andwere previously delegated to the Federal Disaster
Assistance Administration in HUD, the Federal
Preparedness Agency in GSA, and the Defense Civil
Preparedness Agency in DOD. They also included
tasks performed by the White House Office of Science and Technology Policy regarding the reductionof earthquake hazards across the country. On December 7, 1979, the President further charged
FEMA with lead responsibility for radiological emergency planning and a number of other related
specific tasks in his "Response to the Recommendations of the President's Commission on the Accident at Three Mile Island." Thus, since TMI, there
has been a consolidation of Federal functions regarding emergency response to disasters, including
response to radiological hazards from nuclear
In Executive Order 12148, thepowerplants.
President specified certain policies that FEMA must
follow in executing these functions. The Order provides in pertinent part:1210

bill is enacted.) Some of these provisions have particular applicability to coordinated Federal planning:• Section 202(a) of S. 562 provides that the applicant for a "utilization facility" (a nuclear powerplant) operating license shall furnish the NRC withthe emergency plan of the State in which the facili ty is sited, and that no license shall be issued
unless the NRC is satisfied that the plan adequately protects public health and safety.
• Section 202(b) provides that States in which autilization facility has already been licensed tooperate, but which has not obtained NRC concurrence on an emergency plan, must submit
such a plan to the NRC and to FEMA. The NRC,
i n consultation with FEMA, must review the plan2-2. Implementation.
2-201. In executing the functions under this Order,
the Director shall develop policies which providethat all civil defense and civil emergency functions,
resources, and systems of executive agencies are:(a) founded on the use of existing organizations,
resources, and systems to the maximum
extent practicable;organizations,(b) i ntegrated
effectively
withresources, and programs of State and local
governments, the private sector and volunteer
organizations; and(c) developed, tested and utilized to prepare for,mitigate, respond to and recover from theeffects on the population of all forms of emergencies.
2-202. Assignments of civil emergency functions
shall, whenever possible, be based on extensions(under emergency conditions) of the regular mission of the Executive agencies.

for compliance with those NRC guidelines in effect on July 16, 1979. If NRC concurrence is not
obtained by June 1, 1980, the NRC shall ordersuch facilities to terminate operations until a sati sfactory plan is submitted.
• Section 202(c) requires that the NRC promulgate,
within 6 months of enactment of the appropriation bill, minimum requirements for State emergency plans and define a period for expeditious

2-203. For purposes of this Order, "civil emergency" means any accidental, natural, man-caused
or wartime emergency or threat thereof, whichcauses or may cause substantial injury or harm to
the population or substantial damage to or loss ofproperty.

compliance. It provides that the NRC must consult with FEMA in formulating these requirements.
• Section 202(d) provides that the NRC requirements formulated under section 202(c) shall:

2-204. In order that civil defense planning continues to be fully compatible with the Nation's overall
strategic policy, and in order to maintain an effective link between strategic nuclear planning andnuclear attack preparedness planning, the development of civil defense policies and programs by the
Director of the Federal Emergency Management
Agency shall be subject to oversight by the Secretary of Defense and the National Security Council.

Assure protection of the public health and safety to
the maximum extent practicable, and shall at aminimum provide for:

Designation of appropriate planning zones surrounding each facility on the basis of such factors as reactor size, probable release patterns
from possible accident sequences, and demographic and land use patterns;(2) capability to quickly and safely implement protective measures such as evacuation andsheltering;(3) initial and periodic testing of plan feasibility inactual drill of State and local organizations
which are assigned responsibility to carry out
portions of the plan;(4) vesting of responsibility for the development
and revision of the plan in a single agency;(5) participation of facility licensees, local governments, and appropriate State agencies in thatdevelopment and revision;(6) delineation of respective organizational roles in
implementation of the plan; and(7) identification of procedures for expeditious andreliable notification and communication.
(1)

2-205. To the extent authorized by law and within
available resources, the Secretary of Defense shallprovide the Director of the Federal Emergency
Management Agency with support for civil defense
programs in the areas of program development andadministration, technical support, research, communications, transportation, intelligence, and emergency operations.
2-208. All Executive agencies shall cooperate withand assist the Director in the performance of his
functions.

The FY 1980 NRC Appropriations Bill (S 562)

The NRC's appropriations bill for fiscal year 1980
was pending before Congress as of October 30,
1979. The Senate bill under consideration (S. 562)
contains a number of provisions aimed at improving
the NRC and the overall Federal response to emergencies at nuclear powerplants. (Of course, theseprovisions could be changed significantly before theSection 203 requires the NRC to promulgate byrule, within 6 months of enactment of the appropriations bill, an emergency plan for agency response to1211

a National Contingency Plan to provide for expeditious, efficient, and coordinated action to protect
the public health and safety in case of an extraordinary nuclear occurrence, or an event or sequenceof events which significantly increases the likelihood thereof, at a utilization facility licensed under
section 103 or 104b. Such Plan shall include, but
not be limited to -an extraordinary nuclear occurrence. The plan
must provide, at a minimum, "effective and expeditious procedures" for:
(1)

(2)
(3)
(4)

(5)
(6)
(7)
(8)

notification by the licensee of any event or sequence of events at such a facility which may
significantly increase the likelihood of such an
occurrence;
determination of the existence of such an
event, sequence of events, or occurrence;
representation at the facility site vested withthe authority to act on behalf of the Commission;communication among Commission headquarters, the Commission regional office, Commission representatives at the facility site, theGovernor of the State of situs and other appropriate State officials, and senior management officers and operator personnel of thelicensee;comprehensive and definitive monitoring of radiation levels within the boundaries of the facility site;
function of the Chairman as spokesman for theCommission in accordance with Section
201(a)(1) of the Energy Reorganization Act of1974, as amended;making recommendations on evacuation; andacquiring facility design and construction information, equipment, and technical expertise.

(1) designation of an interagency task force, including but not limited to the Federal Emergency
Management Agency, which shall be the leadagency, the Commission, the Environmental Protection Agency, the Department of Health, Education, and Welfare, the Department of Defense,
and the Department of Energy, and consisting of
personnel who are trained, prepared, and available to provide necessary services to carry out
the plan;(2) assignment of duties and responsibilities amongFederal departments and agencies: Provided,
however, that the Environmental Protection
Agency shall have the responsibility for radiation
monitoring outside the boundaries of the facility;(3) identification of an official of the lead agency astask force coordinator at the facility site;(4) establishment of a national center to provide
coordination and direction in Plan implementation; and( 5) identification, procurement, maintenance andstorage of equipment and supplies.

It requires further that,

The President shall incorporate in the Plan required
hereunder the provisions of the plan of the Nuclear
Regulatory Commission promulgated pursuant tosection 203 of the Nuclear Regulatory Commission
Authorization Act for Fiscal Year 1980. To the
maximum extent possible, the Federal response to
an extraordinary nuclear occurrence, or to an eventor sequence of events which significantly increases
the likelihood thereof, at a utilization facility licensed
under section 103 or 104b shall conform to the Plan
The President may
promulgated hereunder.
periodically revise such Plan.

I n the promulgation required hereunder, the Commission shall specifically determine which procedures shall be implemented by majority vote of
the Commission, and which shall be implemented
through delegation of authority.

Section 204 adds a subsection (q) to Section 170

of the Atomic Energy Act of 1954, as amended:

q. Within 120 days of the date of enactment of thissubsection, the President shall prepare and publish1212

I V SAFETY MANAGEMENT FACTORSGERMANE TO THE NUCLEAR REACTOR
ACCIDENT AT THREE MILE ISLAND,MARCH 28, 1979
BY C. O. MILLER, SYSTEM SAFETY, INC.

1. INTRODUCTION
a. Basic Nature of the Accident
Little doubt remains about the principal facts surrounding the events at Three Mile Island (TMI) beginning during the early morning hours of March 28,
1979. In retrospect, they appear relatively simple.
A transient to the system during a routine
maintenance function led to automatic shutdown of
the reactor. A malfunctioning valve interrupted thenormal process of residual heat dissipation andcreated a small loss of coolant accident (LOCA).
Inadequate control room design and personnel
training coupled with poor procedures precluded
timely and proper diagnosis of the problem. Indeed,
the accident would not have occurred, except that
inappropriate shutdown of the emergency corecooling system had been performed.
The reactor was ultimately brought under control,
but not before the accident caused a justifiably perceived threat to thousands of people. Also, thepublic developed a justifiable disillusionment withagencies responsible for nuclear power reactor

safety, including the NRC, which was criticized for
its attitude toward nuclear safety.' Not only was thehandling of the emergency ad hoc, at best, but precursor events-clear warnings that TMI could
occur-were readily found during the many investigations of the accident.
Several relatively new aspects concerning accidents, at least as compared on the surface withother kinds of accidents, are notable. For example,
this was an accident that was not over quickly. Unli ke the crash of a jetliner or even the sometimes
protracted devastation of an earthquake, thedevelopment, recognition, and control of the TMI hazard took days, not hours. Emergency actions, letalone investigative actions, required the combined
talents of countless people in virtually all segmentsof government and the nuclear industry.
A new accident factor, "severe mental stress,"
was imposed upon the public, a factor at least
highlighted if not identified for the first time as adamage criterion against which an accident would
actually be defined. 2 Usually, for investigative purposes, an accident requires some minimum level ofphysical damage to persons or property; otherwise,1213

the event is referred to as an incident, mishap, or3some other relatively mundane term.
A nuclear powerplant represents a unique breedof potential manmade disasters combining the worst
effects of facility hazards, "Act of God" environmental disturbances, and disease. Coupled with a general lack of understanding by the public of the nature and limits of errant nuclear energy as found inpower reactors, the challenge to those in a position
to prevent such potential disasters is profound.
b. Safety Management as an Accident Cause
FactorCommentators in some of the earliest accident
prevention texts have expressed the view that all
accidents, no matter how minor, are the fault of organization. 4 They were not referring to organizationi n the literal sense of simple division of work as ill ustrated by a pyramid shaped chart; rather, they
were speaking of the totality of management, the influence and responsibility of those in authority. In
this vein, and for purposes of this study, safety
management is considered to be the integration ofskills and resources specifically organized toachieve a goal of accident prevention along with allother required management objectives. This isanalogous to similar logical classifications ofmanagement specialization such as fiscal management, schedule management, personnel management, and so forth.
Figure IV-1 further illustrates this precept inmodern terms. It reveals management in the domi nant role controlling the traditional interacting man,machine, and medium (or environment) safety factors; the organization's
mission is the central target
5,6
or objective.
This concept could be broadened toi nclude cost and schedule ramifications and reflects
management's overall continuing fundamental chall enge: To balance the troika of performance (in thiscase safety performance), cost, and schedule.
Figure IV-1 thus becomes a pattern that safety
management can follow in accidents, whether intheir prevention or their investigation. That is, whenanalyzing a safety problem either before or after thefact, the variables shown here, and their relationships, should be examined.
Figure IV-1 also is implicit in the precept of "system safety," which is defined as: "The optimum
degree of safety within the constraints of operational effectiveness, time, and cost attained throughthe specific application of system safety management and engineering principles whereby hazards
are identified and risk minimized throughout allphases of the system life cycle." 7This is a doctrine exercised extensively by the
Department of Defense and the
National Aeronau7-9
tics and Space Administration.
Segments of the
Department of Energy, some agencies of the
Department of Transportation, and the Consumer
Product Safety Commission have also embraced theconcept of system safety in recent years. It forms
the point of reference for much of the analysis contained in this report although system safety terminology and many of its provisions are foreign to theoperation of the Nuclear Regulatory Commission
and other segments of the nuclear energy system.

1214

c. Scope of the Report

As indicated in the title, Section IV analyzes safety management factors germane to the TMI accident. It includes a major part of the system safety
process noted above and examines, specifically, six
areas:• Statutory

•
•

•
•

Considerations-Those backgroundfactors associated with the NRC's enabling legislation which influenced NRC's approach to safety
management;
NRC Safety Policy-The presence of policies(express, implied or, in fact, absent), whichgoverned NRC's safety mission;
Planning-The scope and effect of various safety
plans on NRC's effectiveness;
Requirements and Enforcement-Again, scopeand effect from the management viewpoint;
Safety Tasks-The division of work necessary inan effective safety program in addition to theconcept that safety is implicit in the job of everyone associated with nuclear power generation;
Organization-The assembly of tasks and people
i n a configuration providing efficient and effective
accident prevention.

This analysis does not dwell on the details of the
TMI accident itself since
this is chronicled in
1,10-17
numerous other studies.
Nor does thisanalysis examine safety management performance
typified in the NRC by the Office of Nuclear Material
Safety and Safeguards, whose activities were notdirectly applicable to the TMI event. Other agencies
such as the Government Accounting Office haveprovided or are performing such studies. 18 Finally,ti me constraints have precluded detailed examination of safety management factors as practiced in
the industry itself (utilities and vendors), although
there is strong evidence that concepts of safety
management followed by the NRC have been mirrored by industry.
d. The Positive Side

Like any postaccident analysis, this reporthighlights shortcomings in an attempt to concentrateon those factors about which something practical
can be done to prevent future accidents. As such,the reader is cautioned to remember the overall performance of those charged with the development
and operation of commercial nuclear reactors thus
far. The record has been perfect in terms of absence of fatal injury or even personal injury in theconventional sense of the term. Also, it can beshown that the NRC safety management deficiencies as described herein are also present in many
contemporary industries and have only recently
been appreciated and attacked by some of them.
Furthermore, the reader should not underestimate the value of the existing comprehensive nuclear regulatory requirements that safeguard the
public's health and safety today. Remember too the
exceptional level of professional competence foundgenerally within the NRC, which must function in oneof the highest technologies imaginable, and the extremely complex sociolegal environment that brings
a lot of pressure to bear on the regulatory process
as the price we pay for direct public participation indecisions, pressure that ensures considerable visibility of the regulatory process.
The results of the U.S. nuclear power reactor effort to date have been good. As TMI has shown,however, good is not enough. The public will not
tolerate any performance that reveals, under scrutiny, the absence of reasonable application ofstate-of-the-art techniques to prevent accidents.

1215

Such techniques include not only technology peculiar to nuclear power generation but also techniquesof a more general nature, such as safety management.
e. Perspective of the Author
This study has been prepared as part of a con19
tract with the NRC in connection with the NRCTMI Special Inquiry Group, or SIG (otherwise known
as the Rogovin Investigation), ordered by the Commission. 20 Complete freedom of expression has
been encouraged in the writing of the report, andpersonnel contacted during the study have been
exceedingly candid and cooperative in providing information and documentation. Records, including
depositions, interviews, and material cited as references, are available to the public.
Most of the work products of the Special Inquiry
Group have been subjected to various forms of peer
review. A basic commitment given to the peer review groups has been that differences of view may
not always be resolvable and that they will be reflected in the reports insofar as practical. Thissame approach has been followed in discussions
with NRC personnel and in preparing this report,
which was exclusively the work of the author.
Prior to this undertaking, the author had no association with the Nuclear Regulatory Commission or
the nuclear industry. His education includes an undergraduate degree in aeronautical engineering anda graduate degree in systems management. He is a
graduate of the Federal Executive Institute, and will
be completing his studies towards a law degree in
May 1980.
The author has held senior safety engineeringand management positions in the aerospace industry for over a quarter of a century and in the university environment and the Federal service, the latteras Director of the Bureau of Aviation Safety of the
National Transportation Safety Board from 1968 to
1974. He is an acknowledged pioneer in the systemsafety discipline and has been employed as a consultant to DoD in the development of the 1969 System Safety Program Requirements Standard (MILSTD-882A); to NASA as a safety management consultant after the Apollo fire at Cape Kennedy; to the
Urban Mass Transit Authority as a safety management lecturer in their courses at the Transportation
Safety Institute; and to the National Safety Council
and the American Society of Safety Engineers intheir initial incorporation of system safety techniques into training of personnel in the industrial
safety field.
Thus the author's perspective in preparing thisreport has been one of unfettered inquiry involving arelatively foreign technical field. However, based
upon past experiences with fields equally foreign at
the time, common problems arise when it comes topreventing accidents.

the Commission may be at liberty in its deliberations
to balance safety against competing considerations.
The fact remains, however, that confusion reigns
as to what interpretation should be given to the statutory meaning of nuclear safety now, in 1979, as
opposed to when the law was initially written aquarter of a century ago. The law appears to adopt
the abstract dictionary meaning of absolute freedom
from harm as applicable only to human beings.
Contrast this with more modern interpretations
found in current state-of-the-art safety technology
such as:2. STATUTORY CONSIDERATIONS

For all members of the nuclear power communityand for the NRC in particular, fundamental authorities and limitations for nuclear safety management
are found in the Federal statutes. These involve
principally the Atomic Energy Act of 1954 and theEnergy Reorganization Act of 1974. 22 Interpretations by administrative fiat and court decision may
amplify the statutes, but the foundation of nuclear
safety rests on the legislation. If that foundation isinadequate to support effective safety management,
revisions of the law should be considered.

• Safety (defined)-"Freedom from those conditions that can cause death, injury, occupational
illness,7or damage to or loss of equipment or pro -per'ty."• System Safety Program Objective-" to minimize

loss of personnel and material resources throughmishaps and to preserve the combat26
capability of
the Air Force...." (Emphasis added.)a. Safety Objectives

The Act of 1954 was passed at a time when attention was focused on the catastrophic nature of
accidental detonation of atomic weapons or theiruse against us by an enemy. As a byproduct of
atomic weapons research or simply previous technology related principally to the medical field, radiation hazards to people were also appreciated reasonably well. Accordingly, and without surprise, theAct of 1954 cited safety objectives only in terms of"common defense and security [and] adequate protection to the health and safety of the public."
Significantly, there was little association of safetywith the protection of property or other relatedresources, and what is stated under the Act of 1954
is obscure, seemingly related to facilities used in the
conduct of defense and security activities. 23 Clearly, personnel deposed and interviewed during thisstudy did not view safety as related to the protection of nuclear powerplant facilities themselves.
Also, there was no identification of safety whatsoever as a necessary predicate to mission accomplishment, as compared with military policies related24
to aviation safety beginning in the early 1950s.
The AEC approach to safety was not changed by
the Act of 1974. Accordingly, a strict interpretationof the NRC's statutory base suggests little room forconsidering economic or other factors, which arenecessary for a viable nuclear power capability in
the U.S., if they come into conflict with the "adequate protection to the health and safety" requirement. However, a recent position paper by the NRC
General Counsel states that such a narrow interpretation is not correct and that, "adequate protection"
is a term that focuses on radiological risk and that it
is not synonymous with "public interest." 25 Thus

That this precept is important within the nuclear
power industry is evident by the concern control
room operators have to "save the shutdown" wherever they can in the event of a transient. It is esti mated that it costs a utility between $200 000 and$300 000 a day every time it has to shut down its
nuclear power producing capability.
Acknowledging the effects of accidental losses
on resources and the possible effects of accidental
loss on mission leads to much greater motivation forsafety throughout any organization than does concern with personal injury or death alone.
Finally, the statutes appear to treat safety as acompetitor to development of a viable national nuclear power capability, whereas the impact of TMI
shows clearly that without a reasonable degree ofsafety there would be no nuclear power mission toaccomplish; indeed, there would be no nuclear
powerplants. The statutes avoid the real world
meaning of safety that entails management of risk;
the trading off of time and cost with hazards defined
vectorially in terms of their probability and severity.
b. Regulatory Role of the NRC

1216

The principal purpose of the Act of 1974 was toseparate the nuclear regulatory function from thepromotional function. A review of the legislative history suggests that much of the thinking during
development of the legislation was toward establishi ng a licensing agency as opposed to a regulatory
agency, 27 distinguishable in that licensing is only aprocess by which permission is granted for a party
to perform some desired function, while regulation,on the other hand, has broader meaning. Regulationinated by the actions of the other. Coordination
meetings do occur between the NRC and thecomponents of the DOE formerly grouped under
ERDA, but these meetings are primarily for coordination regarding facility use, emergency planning, and similar administrative matters. It can beargued that ERDA had a mandate to educate thepublic about the realities of nuclear power in thei nterest of promoting nuclear energy. It chose
not to, and the NRC seemed afraid to-at least
until TMI. For reasons described earlier regardi ng the role of safety in mission accomplishment,
this entire division of activities was not only illogical but was never really believed by the public.
Post-TMI criticism of the NRC's relationship withi ndustry is mute testimony to the truth of thatpoint.

entails a prescription of rules of order by a superior
or competent authority relating to actions of those28
It suggests a stronger technounder its control .
logical leadership role than would a simple administrative licensing function. It accounts for a perception by the public of the NRC's national safety accountability; the public believes, and rightly so, thatthe center of nuclear power expertise within theFederal establishment is the NRC.
Unfortunately, the evolution from AEC to NRC
had some counterproductive side effects.

1. Some of the staff who were licensing oriented
never realized their broader responsibilities. The
regulatory process was overwhelmingly geared
to approval of licensing applications rather thancontrol through other means as well.
2. Development of nuclear technologies was left initially to the Energy Research and Development
Administration, although the NRC was given a
research function to support its localized processof developing standards. This resulted in an organizational separation rather than necessary integration of basic and applied research needs.
Not until 1977 did Congress expand the NRC
research responsibility to include research in advanced concepts, systems, and processes withthe potential for improving nuclear safety. 29 Of
course, it will take some time before the resultsof this action become effective.
3. Closely related to the above, at least two safety
efforts which could have impacted on TMI became lost in the transition from AEC to NRC.
One was the growing awareness of the deficiencies in application of human factors engineering
principles to control room design, as typified by
Swain's study of the Zion plant near Chicago.
Although this work was done in 1974 and 1975,
there was an absence of meaningful followup,
which can at least be ascribed partially to the organizational change.
The second31-47
was the development of the
MORT concept,
a safety management program begun in 1972 under the AEC, adopted andamplified in 1975 by ERDA, alive and well in DOE
today, yet unheard of by all but a few Inspection
and Enforcement (IE) personnel within the NRC.
This loss of continuity in applying modem concepts was particularly distressing in that MORT
was an excellent example of technology transferfrom other fields (in this case the aerospace industry) that can often prove very valuable.
4. In an attempt to adhere strictly to the separationof safety regulation from promotion of nuclear
energy, the NRC and ERDA seemed to become
i solated from one another, each carefully restricti ng its activity so that each would not be contam-

Perhaps the most serious deficiency in the statutory heritage of the NRC is the failure of Congress
to realize the true relation between regulatory process and achievable safety. This problem is notunique to nuclear energy; it was pointedly discussed
recently at the GAO Conference of Transportation
Issues of the 1980s by Gerard Brugginkof the Na48
In his retional Transportation Safety Board.
marks, he stated:

1217

The fact of the matter is that any regulatory or
standard-setting activity is only part of the safety
equation. Regulations and standards-even when
they are sound-are no more than abstractions.
They can only aim at a certain level of quality indesign, manufacturing, maintenance, and operations. The achievement of the safety level intended
by rules and standards depends on the recipients'
ability and willingness to satisfy regulatory intent.
Since the ability and willingness to operate within aregulatory framework are governed by a variety offactors, including the caliber of management,
economic pressures, and corporate or individual integrity, we have to allow for corporate and private
initiatives in the safety equation. This means that aregulatory agency at best, can only set a potential
safety level; the actual safety level is determined by
the realities of the market place....
The bottomline in safety is the degree of care
exercised by individuals. The responsibility for theability and willingness to exercise the proper degree of care is shared-in a complex and overlapping way-by the regulatory agency, corporate entities, and individual operators. Whenever the balance between these three areas of responsibility is
disturbed, we can expect the safety problems reflected in the present upswing of fatal accident
rates, because the imbalance brings erosion of individual accountability. Where is the imbalance andwhat can be done about it?
As I see it, the imbalance lies in the disproportionate share of the safety role attributed to the regulatory agency. There is a growing tendency totransfer to government even those safety responsibilities that are purely corporate or personal in nature. Perhaps, we should expect that in an age that

encourages self-indulgence and conditions the citi zen to look at "Big Brother" for solutions to selfi nduced problems....

Unfortunately, the Act of 1974 really did not
speak to these questions. It seemed to recognize
the need to ensure conveyance of information fromthe highly qualified technical staff to the Commissioners, who may or may not possess understandi ng of the nuclear power system. However, in doing
so, the Act laid the foundation for organizational discipline confusion, especially when considering thedoctrine of equality among Commissioners.

Simply stated, there are many accident prevention tasks that do not conveniently or conventionally
fall under the regulatory process, yet are necessary
for an effective safety program. These will be further discussed later.
c. Mandatory Organization at the NRC

Studies both prior to and immediately after TMI
have been critical of the decisionmaking process
followed by the NRC. 1.18 '49 Particular damnations
have been aimed at the role of the Commissioners
i n juxtaposition with the Executive Director forOperations (EDO) and the major offices: Nuclear
Reactor Regulation (NRR), Nuclear Regulatory
Research (RES), Nuclear Material Safety and Safeguards (NMSS), Inspection and Enforcement (IE),and Standards Development (OSD). Accusations
have been leveled regarding lack of leadership, indefinite policies, and policies created by staff andsimply endorsed by higher management. "End run"
communications were alternately encouraged too
much or too little. Authority of the five Commissioners has been described as "20% each," despite a1975 amendment to the Act of 1974 vesting chief
executive authority in the Chairman.so
What seems to have been forgotten, however,
was the mandating in the Act of 1974 by Congressof specific organizational concepts to be applied
within the NRC, namely:• The equal status of each Commissioner without
any specified qualifications for appointment;• The specific delineation of three of the offices(the NRR, RES, and NMSS), as well as EDO;

• A specific prohibition on any EDO attempts to inhibit Office Directors from communicating directlywith the Commissioners except that the EDO canrequire that the Office Directors keep the EDO
informed of such communications, this despite
EDO's assigned responsibility of coordinating theactivity within Offices.

Further, no clear-cut description was made in thestatute of the Commission's role as a group. Were
they a collegial body, an advisory body, an adjudicative panel, a committee form of decisionmaking?
Were they to function by majority rule, by consensus, by individual influence upon senior staff offices? Were they to convey all of their desires, bywhatever method such desires were determined,
through the EDO to the various offices? Were they
to take charge in times of emergency and, if so, asa group or by other arrangement?

3. NRC SAFETY POLICY

Notwithstanding statutory considerations providi ng the foundation for NRC activities, the NRC-likeany Federal agency-is obliged to develop operati ng policies on its own. Legislation can only provide
the necessary authorities and the bounds within
which the agency must function. Indeed, if the statutory base is unduly restrictive in terms of either
scope of activities or authorities, it is obligatory forthe agency to initiate requests for corrective legislation. Thus, blame for operating problems originating
i n the statutes does not shift entirely to theCongress unless it can be shown that the NRC attempted and was thwarted in the proposing of newl aws. No record of this having happened with regard to the above questions has been found.
Safety policy as generated from within the NRC
i s the integrated result of countless documents.
This fact in itself suggests a fundamental problem.
Nevertheless, two particular documents are worthyof attention. The first is the collection of rules andregulations published under Title 10, Chapter 1, Codeof Federal Regulations-Energy. Part 50 is entitled,"Domestic Licensing of Production and Utilization
Facilities," and includes not only administrative
processes implicit in licensing, but also definitions,
technical specifications, and certain safety engineering and management criteria which effectively
define the modus operandi of the NRC. Also included is an "Interim General Statement of Policy" entitled, "Protection Against Accidents in Nuclear Power
Reactors," published on August 27, 1974.
Part 100, "Reactor Site Criteria," of the regulations is complementary to Part 50, particularly inproviding for a last line of defense in the hardware
for accidents which are not prevented through safety engineering of individual systems. Evacuation of
the area, sheltering, and medicinal prophylaxis areother defenses to the effects of radiation; however,their social impact is severe and relatively uncontrollable by the NRC alone.
A second major source of safety policy, muchl ess known than 10 C.F.R. 50 or 100, at least outsideof the NRC, is a report published in draft form in
July, 1973, "The Safety of Nuclear Power Reactors

1218and Related Facilities." WASH 1250. 51 This report
was the nearest thing to a single document text
combining safety philosophy and basic knowledge
about nuclear power reactors found during thisstudy.
What comes through from these documents is atechnology that is very highly oriented to engineeri ng and science, as opposed to people or management orientation, in the effort to achieve accident
prevention. Licensing rather than regulation prevails, in the broad sense discussed earlier in Subsection 2.b. above. Although no one is promising arisk free system, assessment of risk seems to be sohighly emphasized that control of risk, i.e., safety52
assurance, becomes obscured.
More effort
seems to be present in assessing probabilities andmeeting some quantitative goal (admittedly hard to
define) than in examining alternative, practical solutions. Finally, safety is recognized as being implicit
i n every activity of the NRC, yet there seems to be
no recognition of an overall NRC safety policy thati ntegrates efforts of all segments of the organization, especially on a timeline basis.
These and other fundamental policy considerations are amplified in this and subsequent sectionsof the report.

Such a list can be found in the introduction to thewell-known text, "The Technology of Nuclear Safety, " used at the Massachusetts Institute of Technology during their summer nuclear safety courses.
The authors propose that reactor safety should beaimed in such a manner that:

1. There must be no "public safety" accidents;
2. The "Economic Accident" should be prevented;
3. The frequency of the "Industrial Personnel Accident" should be reduced to the lowest possible
l evel;4. The number of "Operational Problems" should be
kept at a minimum.

The need for such a hierarchy is threefold. First,
it indicates clearly that economic losses are significant, which extends the objectives stated literally in55
the NRC's enabling legislation.
Thus, it would allow the NRC to join other Federal agencies in realistic appreciation for the total scope of safety in the
public interest.
Second, and not so obvious, is the need to appreciate that a continuum of events constitutes the
spectrum of hazards that must be examined as aneffective safety program. "Operational Problems"
can and do lead to "Public Safety Accidents" as afunction of the control or lack thereof of intervening
forces. Thus, a safety program geared only to themajor events is depending upon the fickle laws ofchance to gain information of ultimate value in protecting the public.
Finally, the protection of the employees of utility
companies and their onsite associates is anothersafety activity needing integration at the objectives
phase. Otherwise, segregated and less efficient
safety programs downstream will result.

a. Safety Objectives
The statutorily defined objectives for "health andsafety" have given rise to a three level design approach. First, "nuclear power plants are required to
be designed and constructed with a high degree of
reliability." Second, provisions must be present, "toforestall or cope with incidents and malfunctions
that could occur notwithstanding the assurance offered by careful plant design." Third, "safety systems are required to be installed to control all[design basis] events". 53
For example, a particular pump in the primarycooling system must be reliable in itself, then there
may be dual power sources available for the pump,and finally an independent engineered safety feature(in this case an emergency core cooling system)
would be required in the event the pump or pumps
failed to perform their intended function.
I n addition to these measures, there is the concept of containment. This applies at least for toxic(radioactive) materials and, insofar as practical, applies to the effects of physical destruction of the facility from thermal energy sources implicit in thedevelopment of nuclear power.
What is not apparent from the NRC policy documents, however, is a hierarchy of goals toward
which their basic approaches should be applied.

b. Safety Definitions and Principles
Closely aligned with safety objectives is thematter of clear understanding of safety terms. As
noted during the introduction to Section V and in thediscussion of "Statutory Considerations," (Subsection 2.a.), even the simplest words such as "accident" or "safety" have profound impact on understanding and managing an effective safety program.
The Division of Systems Safety within the NRC is
not involved with "system safety" as used by otheragencies or defined in professional safety literature.
The NRR division is highly oriented toward hardware
portions of the whole. "Subsystems," if one were tolook at "system" defined by other agencies,
comprises: "A composite, at any level of complexityof personnel, materials, tools, equipment facilities,
and software ... used together in the i ntended1219

operational or support environment to perform agiven task or achieve a specific ... mission requirement. ,7Other terms can be similarly confusing. Some,like "transient," have relatively peculiar meanings
within the power generation community. Others,
li ke "incidents," have widespread meaning independent of the technology. The result is the same. Any
attempt made whatsoever to implement safety programs involving terms such as objectives, requirements, tasks, and so on, beyond the confines of one
agency, meets with inhibited communication because of semantic difficulties.
This does not necessarily mean requiring standardization. It means a need for clear delineation ofcompeting terminology in documenting policy or requirements.
A close corollary to the simplified definitions
described above is the acknowledgement of certain
fundamental principles related to accident prevention6. These would include:

1. The abstract nature of safety in that safety reallycannot be measured in one application except bycomparison to another.
2. Accidents when defined in terms of some damage criterion are rare events; hazards, which aresimply accident elements that have not occurred,
are common.
3. When approached from an accident prevention
viewpoint as distinguished from the seeking fault,
all accidents involve multiple cause and effect relationships.

Failure to understand these three factors resultsnacouple of difficulties. The first is the meaningi
essattempt to treat accidents as a whole statistilcally. The second, conversely, is the lack of attention to hazards as a part of the whole because of
their low order of probability when considered bythemselves.
Other fundamental safety principles will be identified later. The point here is that a safety policy
should include reference to those principles accepted by the NRC and that such reference should bemade clearly and unequivocally wherever possible.
c. Safety Management Philosophy"Safety management" as a specific term was
unknown or, at best, not appreciated among thosei ndividuals deposed or interviewed in connection
with this part of the SIG study. For example, theStandard Review Plan does not include the concept,ss which is illustrative of the fact that no safety
management requirements are identified as such.

This does not mean, however, that firm and well expressed views are not present on the need to
manage the NRC in attempts to achieve a high levelof nuclear power safety in the public interest. The
problem has been that the division of work among
NRC personnel did not reflect any approach exceptthat safety tasks are implicit in everybody's job. Effective safety management, however, requires
meaningful integration of safety tasks, particularly ifthey flow across organizational lines. These tasks
will be further identified and discussed under Subsection 6, "Safety Tasks."
Review of safety policy documents 10 C.F.R. 50
and 100 and WASH 1250 fail to show safety
management attention to anything other than engineering activities, with one notable exception. Appendix B of 10 C.F.R. 50 (and associated Reg
Guides and Standard Review Plan Requirements)
discusses Quality Assurance programs whereincertain traditional safety oriented quality assuranceorganization and operational management characteristics are required. Unfortunately however they
seem to enter, or at least are reviewed, relatively far
downstream in the nuclear powerplant development
and use cycle. Similarly, design quality assurance
and review seem to be a function more of the integrity of the vendor than of the expertise of theutility or the oversight conducted by the NRC.
Critical by their absence in the NRC's safety
management approach are six items usually identified with the system safety process exercised by
DoD and others listed earlier.

1. A clear statement of a goal as being "the highest
possible degree of safety consistent with various
requirements and cost effectiveness." 8
2. The scope of the system to which the NRC safety management requirements are to be applied.
I n the past this has been severely limited, usuallyto the utility alone, which in turn is expected toi mpose comparable requirements upon its vendors.
3. Life cycle attention paid to the implementation of
the NRC's requirements. Not only has adherence
to progress been evaluated only at very few
discrete points during the plant's life history (atconstruction and operating license issuance) but
also no planned program exists to monitor andevaluate fully and systematically what goes onlater throughout the plant's operational life except
through routine, relatively narrow inspections.
4. Separate identification of a safety function; that is,clear application of generalized safety technology
within the organization applied in those areas thatdemand high levels of objectivity even thoughsafety is part of everyone's obligation. These1220

it i s probably academic anyway in the face ofmodern management theory about responsibility.
It i s difficult at best to have responsibility forsomething over which one has no control. For thisreason it is much more logical to approach the subject on a division-of-work basis. What management
really does is:would include, at the very least, accident and incident investigation, safety planning, and safety
performance evaluation.
5. Creation of an atmosphere-an attitude-thatsafety is a positive contributor, not a constraint,
to a viable nuclear power capability in the UnitedStates.
6. Reliability engineering and quality assurance distinguished from safety engineering and management. The main differences in approach between
these two are the technology to be applied andthe infusion of the human variable into the imprecise and complicated effectiveness equation.

1. Assign a task,
2. Provide authority (and presumably resources) toaccomplish the task, and3. Create additional accountability for the successof the task.

System safety was once characterized by Elwood Driver, Vice Chairman of the National Transportation Safety Board as the "systematic application of the safety art."57 The NRC's safety management philosophy has not been systematic nor does
it appear to have thus far recognized the existenceof artful approaches that might supplement the relatively rigid engineering, scientific, and licensing
methods used to date.

d. Safety Responsibility
A recurring issue encountered during this study
was the question of who had the responsibility forsafety at TMI. Was it the NRC? The utility? The
vendor? Congress? Was it the designer? The
operator? The supervisors?
In a letter to Congressman Udall in 1978, Chairman Hendrie expressed the view that the Energy
Reorganization Act of 1974 placed "full responsibility
for nuclear safety within the Nuclear Regulatory
Commission."58 However, WASH 1250 states:"The safe design, construction and operation ofeach commercial nuclear plant is the direct responsibility of the owner/operator over the life of theplant".51
Acceptance of this responsibility for TMI was aroutine matter in the Preliminary Safety Analysis Report (PSAR) wherein the utility stated that, "Met Ed
will be fully responsible for engineering, design, construction, operation and maintenance of the facility "59
I nterestingly enough, the Final Safety Analysis
Report (FSAR) modified the above to read: "Met Ed
is responsible for the design, engineering, construction, testing, startup and safety operation [of TMI2]."60
Note the absence of the word "fully" in the FSAR.
Was this simply an editorial change? Was it aphraseology suggested by Met Ed's legal counsel?
Investigation failed to review the precise reason but

This means that if, in the final analysis, the task is
not successful, the manager, as delegator, is held asaccountable for the failure as the delegatee.
This is just another way of saying that responsibili ty is never delegated, only tasks and authorities.
The confusion arises when questions connoting
blame are asked, and more often than not thesenior man aboard usually takes the brunt of thecriticism.
When the question applies to safety, however, iti s much more productive to think in positive terms:
Who is in the best position to prevent recurrencesof the accident in question?
Then, because of the principle of multiple cause
and effect relationships, the responsibility must
become shared. That is, if a given accident has
numerous causal factors-and they all do-it follows that multiple sources are capable of providing
remedial action. Hence, all are responsible, collectively, for the accident.
It should be remembered, however, that there is atiming dimension to all this. For example, at a given
moment, such as immediately after an emergency
shutdown of a reactor, o* the utility is in a position
to be responsible or accountable for safety because
the matter must be handled right away. But, if one
l ooks at total responsibility for events leading to the
shutdown, total events during the shutdown, andtotal consequences thereafter, accountability (which
was once responsibility) depends upon who was
assigned what task, what authority was present,
and what performance occurred.
This same precept applies whether accountability
becomes a question between the NRC and a utility,
between offices within the NRC, or between individuals. The highly successful Navy system credited
to Admiral Rickover leans heavily on the personalaccountability doctrine in true command responsibility format. Quite often this doctrine looks with
undisguised distain on sociological and institutional
factors present in the civilian free enterprise nuclear

1221

power system. Nevertheless, the doctrine's
adherents are careful not to look in a single direction when something goes wrong.
e. Organizational Discipline
Any safety management policy and its implementation is only as good as the organizational principles followed in day-to-day operations. An analysisof this in relation to the NRC is made further on (inSubsection g., below). However, one aspect is reviewed here because of its fundamental nature as amatter of NRC policy.
Management of complex endeavors over the past
two to three decades has recognized the necessityof the project manager concept. Not that the staff
advisory function is not also needed to complement
the basic project manager's line or decision task,
but someone must be in control. Decision lines ofauthority must be visible, but they must also be subject to challenge if need be by technical experts
whose prime interest does not encompass cost orschedule considerations.
The result has been a matrix system of management whereby project managers are looked upon as
the decisionmakers and as heads of a teamcomprising technical and administrative experts
from functional areas on as needed basis. The
functional managers, who usually report to the samelevel as do the project managers, then become thecheck and balance force.
The other, frankly outmoded, approach is thatused by the NRC, a system in which project
managers are only coordinators and recordkeepers.62 It was not always that way. As recently
as 1971-1972, project managers ran their own
shows. However, as technology came to the NRC
in vast quantities of highly skilled engineering andscientific personnel, the "functional groups
took over63
the whip hand," and they have it today.
Since it is beyond the capability of one person tohandle ultimately the myriad of projects within the
NRC's purview, a key question arises. Should supervisory substructure be established within a functional organization or within a project area, and who
has primary decision accountability? Modem project management theory suggests that to delegate
the decision task to the functional party opens thedoor to decisions being made on narrow technicalgrounds without consideration of the full scope ofi ssues. Conversely, of course, a project manager
can fail miserably if he does not communicate withhis technical team members.

The events of TMI-2 seem to suggest that an excessively narrow technical view of potential safetyi ssues was taken. Certain project management
functions, such as monitoring and effecting corrective action on precursor events went unattended.
Two observations surrounding the time period inwhich TMI occurred are particularly illustrative of theill-effects of an excessively strong technical function. First, an examination of the "unresolved safetyi ssues" in NUREG 510 reveals that all of these is64
sues are strongly engineering or science oriented.
None of them are aimed at those institutional probl ems that have been raised by all parties who havei nvestigated TMI, the kinds of problems faced routinely by project managers, not by coordinators.
This is not to deny the importance of the technicalsafety issues, but it should be pointed out that resol ution of those technical problems do not create asafe system in the broad context.
Second was the apparent breakdown in handlingthe genuine safety concerns encountered by field
65
This
personnel, as shown in the Creswell memo.
breakdown occurred despite an aggressive NRC
66
policy effort to counter tendencies in this regard.
Someone (or, more practically, some office) should
be in a position to monitor and direct the NRC effort
as necessary regarding a given facility from the day
it is conceived until the day it is buried. This system
life cycle concept applies well beyond safety ramifications and has been implicit in systems management doctrine for years, especially in DoD.
The point has been proffered that DoD can apply
system safety or systems management techniquesmuch easier than they can be applied in civilian, freeenterprise endeavors. This is probably true in that
selection and control of people is probably easierwithin the military. Also, it is easier to get a mission
requirement accepted in a defense environment
than in 50 different states with 50 sets of laws anda relatively uniformed public. Finally, the military is acombined buyer, regulator, and operator of the system, and therefore procurement, testing, andevaluation are much simpler.
Still, in either case, it becomes a matter of effectively bringing all resources together to get a job
done. The fact that some of these "resources" areprivate companies or associates as well as government would not seem to present insurmountablesystems problems to life cycle management.
f. Recognition of Human Factors
Analysis of accident causes in any field, simple orcomplex, reveals the impact of human performance.
1222

Even in highly automated systems, human error canbecome involved, either in the maintenance area or
during operations. Certainly the events at TMI-2
proved this once again.
Significant, therefore, by their absence from any
NRC policy statements are any references to thespecific role control room operators play in avoiding
accidents or mitigating their results, other than "justfollowing procedures." Nothing is found in 10 C.F.R.
Part 50, for example, that spells out as a matter ofpolicy the attention to be paid to human components in the system. Similarly, the Standard Format and Control of Safety Analysis Reports (RegGuide 1.70) has minimal reference to anything concerning "human factors," whether the term is used
to identify the discipline related to understanding
and controlling human behavior or simply as a ge67
neric classification of human input to the system.
As discussed in depth in the Essex Corporation
68
report, the TMI-2 control room was not designed
to modern, contemporary standards and did notl ook beyond the nuclear industry for the state of theart. Also, there were no NRC human factors requirements for the control room or for related traini ng and procedural matters; hence, no one at the
NRC reviewed TMI-2 in this regard. These facts
serve to illustrate the relation between policy andrequirements. The former must be present to induce realistic development of the latter.
Approached differently, resources to be integrated as part of a safety management effort are mostoften thought of in terms of funds, facilities, and organizations or agencies. Another resource to be
managed is the innate skill of individuals in the system. A policy should indicate how such skills will be
used and what control philosophy should be imposed upon them.
4. SAFETY PLANNING
One of the fundamental elements of managementi s planning. To be effective it too must be based ona sound policy and defined objectives. It must also
identify all the participants, delineate tasks clearly,
provide a realistic time base, and include methodsof performance assessment. It should be a dynamic
document; that is, it should be subject to change at
discrete review intervals. Its effectiveness is not
only a function of the thought processes which leadto its construction but also the documentation andcommunication of the results.
Safety management technology has identified five
types of plans. They range from an overall programplan with amplified areas to those which are con1223

tingent upon the happening of certain events. This
spectrum of management effort in the context of the
NRC and nuclear power safety is discussed below.
a. Accident Prevention Program Plan
I n theory there should be an overall national nuclear accident prevention plan. This need was expressed indirectly by a member of the ACRS, who
said: "The technological community cannot be
separated from the political community or the social
environment in establishing a suitable regulatory climate. The public will have to determine through legislative or other political processes how the techno69
logical issues will be resolved."
The NRC Lessons Learned Task Force was evenmore direct when they stated: "What seems to be
missing is the common denominator of an articulate
70
and widely noticed national nuclear safety policy,"
but added, "with which to bind together the narrowand highly technical licensing requirements."
This latter qualification is unfortunate not only because comprehensive long range planning has beennonexistent in the nuclear safety field but also because what has been done has been "narrow andhighly technical." Witness, for example, the scopeof 10 C.F.R. 50, Safety Analysis Review requirements.
Since the concept of a national plan is new, according to personnel contacted during the study, its
creation would require leadership across legislativeand executive lines. This raises the question of amechanism for such an effort. The Commission
would logically be the driving force, but the scope ofsuch a program goes well beyond the NRC's charter. This suggests that a White House or Congressionally sponsored effort that could be part of amuch needed broader based
national safety policy
71,72
activity would be required.
b. Safety Engineering Plan
Specific safety engineering plans have been
i dentified with military aerospace systems for nearly73
Modern requirements as indicated
two decades.
i n MIL-STD-882A include such elements as:• System safety engineering management responsibilities,• System safety organization,• System safety program milestones and reviews,• System safety requirements,• Hazard analyses,

• Data requirements,• Safety testing and demonstrations,• Training,• Audit programs.

This typifies a somewhat broader military interpretation of "engineering" than might be encountered in academic circles. The military tends toclassify everything done prior to the operations
phase as "engineering"; hence a system safety engineering plan delves into matters well beyond theapplication of knowledge of mathematical or physical sciences.
Of course the NRC has a direct equivalent to thisform of planning in the requirements for Safety
Analysis Reports. The perspective is somewhat different; that is, licensing rather than planning. However, with relatively minor exceptions, the elementsof a military system safety engineering program canbe found in the process required by the NRC.
What is different substantively, however, is thel ack of an organized framework for the NRC tomonitor the work from the earliest design phasethrough construction and testing. Design safety reviews, for example, are not conducted by the NRC
with the regularity or independence characterizing
DoD or NASA reviews. Similarly, the Quality Assurance program (Appendix B of 10 C.F.R. 50) underscores the potential licensee's promised efforts,
not how NRC wants things done and how it will
check for compliance.
c. Operational Safety Plan
This type of plan is complementary to the safetyengineering plan in that it details how the operating
unit will function once the system has moved
beyond past the test and evaluation phases. In the
military this is a command responsibility which iscarried out at various echelons as required.
The elements cited above from MIL-STD-882 forthe engineering phase have their counterparts in theoperations phase. The words might change slightly
but there are still management organization, program review, hazard analysis, data factors, and other factors to be considered in the field.
In civilian nuclear power reactor activity, the planning function falls logically upon the licensee, withappropriate guidance and requirements from the
NRC. Once again, most desired requirements typified by 10 C.F.R. 50 and 100 are present in principle.
They do not however reflect an easily identifiable
operational safety plan. Nor is there any specificprogram for periodic review of how these plans arebeing carried out or updated.

d. Accident-Incident Investigation Plan
An accident-incident investigation is the derivation of facts, conditions, and circumstances concerning an event in an effort to analyze their meanings relative to some predetermined objective. In
the safety context, that objective is prevention of future accidents rather than enforcement or punitive
measures.
It came as quite a surprise, during this study, tofind that virtually no planning for this function existed prior to TMI-2. Emergency response plans exi sted to be sure, but no procedure or other documentation spoke to authorities, assignments of personnel, techniques, etc., which could be applied toinvestigation as defined above. The nearest thing tostanding investigative capabilities was an Incident
74
Investigation Review Committee that had been in75
stituted after the Brown's Ferry Fire in 1975.
However, the committee's functions have neverbeen exercised. This was possibly due to the lackof significant events, but was probably also due tothe fact that one staff position, that of Chairman,
had been vacant for approximately a year.
As late as several months after the TMI accident,
no identified and validated photographs existed of
the control room configuration. Certainly none weretaken or at least made available to the NRC on
March 28, 1979, or during the following critical days.
The formal investigation did not begin until April 10,
1979, two weeks after the accident. Even the NRC
i nterviews with the key participants, the control
room operators, were not conducted until April 6,
1979, and then on a basis of noninterference with76
Although Region I dispatched
their other duties.
two investigators with the initial response team, bothwere assigned duties other than investigation.
This entire subject was addressed indirectly incorrespondence in 1977-1978 between Dr. Harold
Lewis, then chairman of the committee reviewing the77
Rasmussen Reactor Safety Study, WASH 1400;
the Honorable Morris Udall, House of Representatives; Dr. Stephen Lawroski, Chairman of the ACRS;
and Dr. Hendrie, Chairman of the NRC . 52,s,78-8l
Dr. Lewis had recommended the creation of a nuclear accident review board. The ultimate outcome
was a suggestion in December 1978 by Chairman
Hendrie to the ACRS "to set up a suitable subgroup
to make a trial review of incidents and oc78
currences." Progress in this area has not been reported.
I mplicit in Dr. Lewis' suggestion was the necessity for extensive accident investigation planning, including criteria for choosing events to be investigated, as well as the other specifics noted earlier.
1224

Additional commentary on this subject will befound in Subsection 6.
e. Emergency Response Plan
This function differs from investigation planning inthat it aims at mitigating or otherwise controlling thedamage resulting from the accident. It parallels or
supplements an investigation plan only in its notification of appropriate parties.
Whereas it can be argued that the NRC has themost basic investigation authority and obligation, theemergency response effort involves numerous otherparties, most of them actually located at the site of
the accident.
The NRC Incident Response Program provides
for detailed notification and assembly of NRC personnel in the event of an incident; however, in addition to its failure to account for the investigatory
function except in the enforcement sense, 82 its provisions do not appreciate the differing time frames inwhich accident or incidents occur. Nor are decisionmaking lines of authority or limits clear in theprocedures described in the manual. As is discussed in other sections of the SIG report, 83 theemergency response system failed miserably interms of command and control of the situation. It isperhaps not surprising then that the companion accident investigation function became lost in the confusion.
f. Planning Life Cycle Considerations
The protracted time period required for developing and licensing a nuclear powerplant (which cantake a decade, give or take a couple of years), provides numerous frustrations for effective planningand followup, not the least of which are personnel
and state-of-the-art changes. This places all themore importance on the clear documentation of requirements, assumptions, bases for changes, elements of compromise, and the like.
Difficult as it may seem, it is acutely essential tohave operational personnel participating during planning at early points of the life cycle. No less important is the need to have engineering personnel
present as the planning reaches and proceeds
through operational stages. This implies possible
support activities, to one degree or another,throughout the life cycle by all of the personnel inthe system: representatives of the NRC, the licensee, his vendors, the architect and engineer,
perhaps State and local representatives, and so on.
1225"Life cycle," as such, and its phases have notbeen a clear matter of record within84the NRC. From
the Project Manager's Handbook,the following
discrete milestones can be derived:

1. I nitial meeting, between the potential licensee and
NRC;
2. Similar preapplication meetings;
3. Construction permit (CP) application and review(ACRS and public hearings);
4. Post CP meetings during construction;
5. Operating license (OL) application and review;
6. Hot functional tests;
7. Online operations begun.

However, these are not programmed in a manner
to indicate conventional systems management
phasing such as design concept, detail design, construction and production, test and checkout, operations, and shutdown. 85 NRC's approach seems toi mply only two phases, construction and operation,
an approach that does not lend the regulatory
framework to sufficient control during the criticaldesign efforts, including those at the very earlystages. Ad hoc "initial," "preapplication," or "postCP" sessions are no substitute for discrete reviews
at a time when costs of changes can be minimized.
It can be argued that because of the uniquebuyer-seller-regulator relationships, in the nuclear
power industry, extensive safety planning effort
cannot be accomplished without overly aggressive
regulatory requirements. Alternatively, standards
can be presumably developed and adopted by theprivate sector in management approaches as wellas in technical areas. It is enough to say that experience in DoD suggests that the various forms ofsystem safety plans discussed above have had ahighly beneficial coordination and safety motivational
effect on all parties. How they come about is immaterial.
g. Legal Interface with System Development
There seems to be a growing concern that thehearing process required by law for licensing is havi ng deleterious side effects in the safety review
sense. To be sure the hearings provide a valued
opportunity for public input and a forum in which issues can be documented and decided. Neverthel ess, practical limits exist on the number of hearings
that can be held and the manhours that can bespent in preparing for the sessions and analyzing
the results.
As indicated above, more definitive safety planning is probably required. But is such planning toproduce a more safety efficient, integrated, andtimely program, or will it go the way of Safety
Evaluation Review (SER) reports? According to discussion within the Advisory Committee for Reactor
Safeguards (ACRS), SERs represent "boilerplate information intended mainly for legal purposes." 86
Similarly, in making reference to the public hearings,
one ACRS member said, "the quasi legal approach
87
There were noi s lousing up the safety review."
dissenters.
The solution would seem to be to provide a system which documents for the record the intent of
the working parties: the NRC, the licensee, the vendors. etc. Thereafter, at reasonable, discrete
i ntervals-some possibly coming very early-status
reports would be made, public input would be obtained, and adjudicatory decisions rendered asnecessary. This is perhaps not too different fromprocedures followed in recent years except that thesafety issues are often lost in a plethora of technical, administrative, and legal detail not comprehendible by many NRC people, let alone members of the
public. Providing more visibility to safety planningand resultant program reviews would seem to bebeneficial.
A vital corollary to the planning and review functions is the effect of safety decisions on the ratebase allowed the utilities as the facility progresses
down its life cycle, including the operations phases.
If the safety planning is more discrete, the socioeconomic legal issues could more readily be adjudicated in the utility's interest as well as that of the
public.
5. REQUIREMENTS AND ENFORCEMENT
a. Basic Philosophy of Requirements
Requirements and their appropriate enforcement
are a fundamental part of any management program; within a given organization this program iscalled "direction of the staff." Between separate
agencies such as the NRC and its licensees it iscalled "regulation."With the structuring of requirements, as in theaccomplishment of any safety oriented task, certain
precepts must be understood so that both the regulator and the regulated know where they stand. For
example, the Act of 1954 proposed minimum safety
and security regulations, and the General Design
Criteria for Nuclear Power, Appendix A of 10 C.F.R.
50 states:

These General Design Criteria establish minimum
requirements for the principal design criteria forwater-cooled nuclear power plants similar in design

for which construction permits have been issued.... (Emphasis added.)

However, the Appendix goes on to say:

The General Design criteria are also considered tobe generally applicable to other types of nuclear
power units and are intended to provide guidancein establishing the principal design criteria for othersuch units .... [The omission of criteria not yet defined] does not relieve any applicant from considering these matters [important to safety] in the designof a specific facility and satisfying the necessary
safety requirements.

Question: Are the requirements issued by the
NRC minimum requirements or are the licensee andtheir vendoi s obligated in the public interest to go
beyond the NRC's immediate requirements? The
answer to both is probably "yes."
Some agencies, the FAA for example, which has
a Congressional mandate to provide adequately fornational security and safety in air commerce, publicly proclaim that their standards are minimum standards; aircraft manufacturers and operators as amatter of business choice usually exceed thesestandards. The DoD uses the absolute "thou shalt
do this" approach instead of the FAA's minimum
standards approach, which can be stated as, "thoushalt do at least this."
Considering the confusion that seems to prevailat the NRC as to what constitutes adequate protection of the public, 25 undoubtedly confusion exists
for the licensees and their vendors. Certainly, if
they believe they are obligated just to meet the
NRC's standards, they will be continually behind theavailable state of the art because of the delay needed to develop and issue any requirement. Furthermore, if the NRC does not do its job, as was thecase with control room human engineering requirements for TMI, criticism will be heaped upon theli censee and vendor as well as the government.
In terms of legal liability positions of the utilities
and vendors, it seems clear that adherence toFederal standards is no appreciable defense and nobenefit to them in any action that might arise following a nuclear accident. First, the newness if not thenature of nuclear energy would probably result in
the courts' applying strict liability under an "abnormally dangerous" theory. 88 Second, as typified byrecent developments in product liability law, thecourts generally do not look to the statutes defining
technical requirements as a test of state of the art
since, as has been the case with the NRC, thelanguage is usually ambiguous. 89 Thus the approachto standards imposed upon the industry shouldhave relatively little impact on their tort liability posture. Of course the Federal Government is excusedunder the discretionary function exception to the1226Federal Tort Claims Act. 90 Accordingly, the choice
between minimum or absolute standards turns moreon socioeconomic factors than on law, especiallywhen the statutes and administrative rules are ambiguous on the subject.
A strong argument can be made for adoption of aminimum standards approach being preferable in afree enterprise versus State-owned utility system.
Only in this manner can the motivation for satisfactory performance, including reasonable advances inthe state of the art, be expected, because of theforcing function of competition. Most important ofall, however, is to be certain all the players know
which game is being played.

evaluated the utility "to determine if the applicant istechnically qualified to safely operate the plant."(Emphasis added) In the SER for TMI-2 in 1976
under the heading of "Principal Review Matters,"
there were no references made whatsoever tomanagement matters.
The TMI accident has shown clearly that the NRC
must go into the management requirements aspects
far more than it has in the past. It should not, however, be restricted only to "technical" qualificationsof supervisors, which seem to have received thebulk of the criticism thus far.

b. Scope of Requirements

Three questionable precepts were encountered
while examining the NRC's approach to safety engineering. The first two of them, the "design basis
accident" and the "safety grade system," were encountered for the first time. The third, the use or attempted use of quantitative approaches to safety
has been quite controversial over the years and has
a long history of various groups trying very unsuccessfully to use it in dealing with requirements.
Design basis accidents are defined indirectly in
10 C.F.R. 50.2(u) in terms of specific functions, controlling parameters, restraints implicit in the state of
the art, and the forecast effects of the postulated
event. They have also been defined succinctly by
Hanauer as "a sequence of events prescribed as
the foundation for the safety evaluation of aplant."95 They had formerly been equated to "credi ble" and "incredible" events; however, that terminology has been largely discarded in recent years
although it is still found in 10 C.F.R. 100.
The design basis accident concept got mixed
reactions concerning the TMI accident. Insofar as it
led to development of containment and various systems that performed better and with more flexibility
than might have been expected, the concept was
successful. When measured against the failure toappreciate control operator actions on the progression of the transient, analysis in terms of designbasis accidents leaves much to be desired.
The lesson to be learned seems to be that designbasis accidents are a valuable approach as long asother hypothetical accidents are constructed figuratively, if not literally, encompassing those factorsthat could not be forecast. In other words, any approach to analysis must anticipate l ack ofknowledge at the time and develop a position ame nable to upgrading as operational data become available.
This leads to examination of the "safety grade
system" precept because it, too, attempts to narrow

The preceding discussion notwithstanding, NRC
requirements in the engineering technical areas are
generally comprehensive and well documented in 10
C.F.R. 50, the Reg Guides, and the Standard Review
Plans. They are, however, only "performance andreliability" oriented. That is, performance is specified through the use of acceptance criteria "for a setof design basis events... [and] reliability, in its
broadest sense, is specified through a set of overallrequirements in the General Design Criteria that address quality assurance, seismic and natural
phenomena...." There appear to be no design process specifications such as requirements for a human factors engineering program effort or, as will be
described more in Subsection 6, no life cycle approach to hazard analysis. These are analogous tosome of the Quality Assurance Program requirements, but applied to the design process not tomanufacture, construction, or operation.
The virtual lack of the human factors or personnel subsystem requirements during design was themost glaring inadequacy within the scope of the
NRC requirements. This is especially true in view ofstudies, some of which were done by the NRC,
identifying the problem as early as 1972. At least
part of this problem can be traced to the lack of human factors professionals on the staff. Phrased differently, if new technologies or methods aredeveloped, it would be strange to see them reflected in requirements unless there were staff members
qualified in the field on board.
Still another requirements area needing considerable upgrading is program management by the utility, management that must start well before theoperations phase as described currently in ANSI
N18.7 92 and endorsed by the NRC as part of a required quality assurance program in Reg Guide
1.33. 93 For example, for TMI-1 in 1973, the AEC
1227

c. Questionable Requirements Precepts

the areas of detailed safety analysis and requirements. Granted, practical economic facts of life
suggest drawing the line somewhere on redundancy, manufacturing and quality control tolerances,
etc., but the designation of "safety grade" must be
made not just on intended performance of the system but rather based on the effects of nonperformance of the system and its associates both
upstream and downstream in the functional chain
being examined. A good example of this was thereaction of control room operators who chose not
to believe certain instruments during the TMI transient because the instruments were not "safety rel ated." 68
The real problem arises when a design basis accident assumes certain performance of a safety
grade system only to find that a nonsafety grade
component or system is the critical one-like theemergency feedwater system or the pilot operated
relief valve during the TMI sequence.
Finally, considerable discussion had preceded
TMI and was resurrected afterwards about establi shing quantitative safety goals or otherwise using
numerical approaches to safety analysis. This has
been in fashion among engineers and scientists and,i n recent years, among managers as well. How
much of this situation rests with the cognitive process within the individuals and how much of it is a
psychologically induced prayer for simple solutions
to complex problems is open to considerable debate. Nevertheless it is a serious question when it
comes to requirements and their enforcement.
Over the years, many attempts have been madeto quantify safety. Urged on primarily by practitioners of reliability engineering, exhaustive failure modeand effects analysis (FMEAs) were developed using
the most sophisticated computer based statisticalanalysis techniques. Early as well as current problems in considering safety analysis rest on several
factors:

1. The small numbers effects inherent in accidents
versus hazards.
2. The lack of good investigative results of failures,
i ncidents, and in some respects even accidents;that is, poor base data.
3. The failure to understand that human performance, even in the face of other systems failures,
can be a positive influence, as well as a negative
one, on performance.
4. The inability to account for nonfunctional failures,as when the stress level simply was not predictable because the environment factors either were
not known or were simply misunderstood.
On the positive side, by disciplined enforcementof thought processes (which mathematical ap-

proaches tend to encourage), one hopefully will
grasp the gestalt-the whole picture. Of course thiscan only occur if the analyst is mature enough torecognize voids in the data or his logic. Also of nosmall value in quantitative approaches to safety isgiving the public what it wants: a nice simple
answer.
The Rasmussen report, 96 was a monumental ef97
fort to sort these things out. The Lewis Report
was even better in that it brought realism to thevalue of statistical analysis as applied to nuclear
power reactors. It properly discouraged looking at
absolute risk and attempts to quantify the unquantif iable. It properly encouraged continued research
i nto areas of vague data so that comparative levelsof safety between given designs could be made-a
process which for years has been meaningful.
Perhaps the Lewis Report's most important lesson to the TMI postaccident machinations about
quantitative approaches to safety is its declarationof the difference between the perceived level of acceptable risk and an objective estimation of risk.
That perception in turn hangs heavily on the credibili ty of the NRC.
Of concern in the final stages of the present
study was a statement within a generally excellent
discussion in the Lessons Learned Task Force report that stated:
In circumstances ... where there are methods anda growing body of data to quantitatively analyze
and measure performance parameters, the quantitative goal is a powerful tool in providing informed,balanced decisions. 98 (Emphasis added.)

One can only hope that "in providing" was merely
an editorial oversight and a better phrase would
have been "to aid in." Quantitative approaches tosafety either quoted as a goal or as a method ofcomparative analysis are not substitutes for humanj udgment. If, in fact the analysis reveals such a
disparity in choices that it makes the decision forthe man, the analysis probably did not have to bedone in the first place.
d. Enforcement Discretionary Function

The Office of Inspection and Enforcement, byl ogical interpretation of its title, is the "policeman on
the block." Viewed by any of the potentially accusedli censee personnel, the NRC inspector wears a
black hat-the villain in an otherwise peaceful exi stence.
To be sure, the above implicitly negative description is oversimplified at best. Policeman are vital tothe protection of society, as are inspectors in theachievement of nuclear safety. The laws or rules in1228

place are only as good as the informed enforcement
given them. Furthermore, as any policeman or inspector will admit, the informal channels of communication used with discretion are at least as effective, if not more so, than raising a billy or writing
a citation.
Enforcement, however, does not begin with thefield activities cited above; particularly up to the time
an operating license is granted, nuclear reactor
safety rules are not only written but are enforced bya different organization, the NRR. The appellatefunction to either IE or NRR actions can extend to
the Commission and to the Federal courts whereappropriate.
By comparison with IE, NRR wears a white hat,
although it can be considered rather gray by alicensee faced with delays in license issuance orbackfit requirements. Criteria against which action
or inaction is evaluated are less strictly defined inmatters before the NRR. In theory, therefore, an adversary relationship should not be present.
Nevertheless, the licensee will often be highly defensive, even when the licensee initiates the contact
with the NRC.
This elementary recapitulation of the role of IE in
relation to the NRR is provided to stress several
things not necessarily apparent when viewed fromeither the vantage point of IE or NRR. The development and enforcement of requirements does notstop at any organizational line of authority. Nordoes it occur at one time in the life cycle of a nuclear powerplant. It is a dynamic and sometimes
iterative process. It requires the highest level ofcoordination in establishing the rules, understanding
them, and applying them. It requires a recognition
that neither the black hat nor the white hat approach by itself can fully and properly influence thelicensee's behavior towards nuclear safety. This
becomes particularly important when consideringsafety communications, as will be discussed more in
the next section.
What remains here is to recognize that "prosecutorial discretion," as Bickwit called it, 25 is a way oflife throughout the NRC. Policies and procedures toprovide consistent application thereof are not wellunderstood, albeit attempts were made in the past
to be definitive. However, written guidance tended
to oversimplify matters by requiring "corrective ac99
tion for each identified item of noncompliance."
One would prefer to think prosecutorial discretion is
not so much a question of mandatory wrist slapping
as a matter of when and how far authority should be
exercised.
A good example of this was raised by the ACRS
i n a letter to Chairman Hendrie concerning the IE investigation of TMI-2. 100 Commenting upon the ac-tions of the control room operators, ACRS Chairman
Carbon stated:

The question ... arises whether an operator, using
his best judgment, is guilty of a violation if he con sciously takes an action that is at variance with procedures which, in themselves, may contain confusi ng or incorrect guidance. The committee believes
that, if so, this is the wrong approach to protecting
the health and safety of the public....

Requirements are only as good as their completeness, clarity, and informed enforcement.
6. SAFETY TASKSOver the past two to three decades, several
tasks within management's division of work have5
become identified as part of safety technology, s
not that they have not been or could not be performed under some other classification of work. It isjust that indepth knowledge has developed andbeen applied in certain areas such that specialization has taken place, and "safety" has become its
generic classification. This is not unlike subclassifications developed in engineering over the years,
one being "nuclear."Three of these safety task areas have alreadybeen discussed: policy, plans, and requirementswith enforcement. In those areas, however, safety
technology is usually just a contributor to very large
functions which go well beyond accident prevention.
I n the areas that follow, safety technology plays a
predominant role in accomplishing the task; it is not,however, an exclusive role and interfaces with manyother technologies.
a. Hazard Analysis
For purposes of this discussion, an immediate
distinction must be made between hazard analysis
and certain techniques in use by the NRC and thenuclear industry usually referred to as Failure Modeand Effects Analysis (FMEA). First of all, hazard is amuch broader term than failure. A hazard is a riskof loss or harm. It is an existing or potential condition that can result in a mishap. ? More often than
not it combines several factors. For example, fuel inan undesired location, where uncontrolled ignition
might take place, is a hazard, whereas the fuel itself
i s not. A failure, on the other hand, is usually defined in terms of something not functioning in themanner for which it was intended. Analyses offailures sometimes reference the environment inwhich the failure occurred, but fundamentally a haz1229

and and a failure are not necessarily the samething. Consequence of a failure can produce a hazard or it can be meaningless toward safety.
Hazard analysis includes FMEAs as one of thepossible valued inputs to an entire hazard analysis
program. In view of the semantic distinction madeabove, however, it should be obvious that safety
demands hazard analysis, not just failure analysis.

Another less obvious distinction becomes apparent only after one examines the techniques used
i n hazard analyses and failure analyses. Historicall y, failure analyses were developed to ensure reliability of the system; that is, the system's ability toperform its intended function within certain failure
rate limits. They were consequence oriented anal yses only in that sense, not with respect to probable damage to persons or equipment. They wereoriented to probability. Moreover their process did
not identify necessary information for accident
prevention such as symptoms of impending failure
or intersystem effects. Nor did failure analyses usually include the input of man as an operator. Thebase error rate data were not available.
Failure analyses start at the part, or component,l evel, and their logic traces the failure effects toward
some system or mission level of performance. Hazard analyses on the other hand are consequenceoriented in the sense of analyzing and preventing
certain broad categories of accidents. They apply
l ogic from the top down, from the undesired event
toward any factors singly or in combination which, if
eliminated or controlled, would prevent or at least
mitigate damage. They do-or at least shouldstress the impact of human performance and be
alert for signals generated by failures (mechanical or
human) that can be controlled before damage ensues. Hazard analyses attempt quantification anddeal in probabilities as do the reliability oriented
failure analyses. However, the bitter lessons of thepast have demonstrated this is a useless task except under highly controlled conditions, and then
only in a comparative sense between relatively easily defined systems.
Above all, hazard analyses, unlike failure anal yses, are life cycle oriented. (See Figure IV-2.) Their
effectiveness rests in several stages of performance, with each new stage building upon
101the previous one as new information is available.
Only inthis manner can one assess the validity of assumptions made earlier which, if proven false by test or
operational results, can highlight accident prevention
action necessary before proceeding further downstream.

As a minimum, these hazard analysis phases include:• Preliminary Hazard Analysis-A gross assess-ment of risk and identification of safety criticalareas needing detailed study.
• Subsystem Hazard Analysis-The identificationof hazards associated with component failures
and functional relationships with other components or equipment in a given system.
• System Hazard Analysis-An examination of theeffects identified in subsystem analysis with othersubsystems including the software that may accompany either.
• Operating and Support Hazard Analysis-The inclusion of those factors in the operating environment (including people performance) which candegrade even the best engineered system.
• Accident-Incident Analysis-The
necessary
feedback process which assesses the validity ofassumptions made in the previous analysis andupgrades the results as needed.

To be effective, this process must include humanfactors considerations throughout the entire
Examination of hardware
analysis life cycle.
characteristics in isolation from potential human inputs is the ultimate in safety technology naivete.
Similarly, procedures and training become subsystems of the overall system to be analyzed.
The NRC's approach and, presumably, the nuclear industry's approach to analyses germane tosafety is reflected in 10 C.F.R. Parts 50 and 100,
Reg Guide 1.70, which is the Safety
Analysis Re67
ports requirements document,
and comparable
sections of the Standard Review Plan (SRP). 102 Recently, the NRC responded to the President's Commission regarding the use of Failure Modes and Effects Analysis. The response included a survey of
10 NRC technical branches as to their use of techniques 1 03 From a review of these documents, asearch of nuclear industry oriented hazard andfailure analysis references in the NRC technicalli59,95
brary, and depositions of key NRC personnel
the following conclusions were reached:
1. Comparatively little, if any, understanding exists
at the NRC of the difference between a reliability
oriented FMEA and safety oriented hazard
analysis. Industry recognition of the difference
was reflected in two 1975 papers; however, they
were not related to the broad based, life cycle
104,105
approach to hazard analysis cited above.
2. The NRC does not require any particular format
for either FMEAs or other forms of analysis.

1230

FIGURE IV-2. Hazard Analysis Phases Within a Program Life Cycle(Adapted from Miller, Ref. 101)
3. Even for so-called "safety analyses" in the "Accident Analysis" chapter of the SRP requirements
manual, questions asked pertain mainly to output
characteristics of given hardware systems
failures rather than examining what hazards canreally develop. Phrased differently, the results ofassessed failures are sought in terms of radiologi cal consequences, rather than first examining
what events can produce the undesired results
and what can be done to prevent those results.
4. Little if anything is done either by the NRC or theindustry beyond the system analysis phase noted
above, thereby failing to identify safety degradation possible from operational factors. Further,no structured feedback loop exists where operational experiences upgrade or otherwise test theanalyses made earlier.
5. Reporting of results of analyses as shown in
SARs is primitive; for example, tables columns
are labeled simply "component," "malfunction,"and "comment." 106 One only needs to compare
this to the extensive guidance and format identi-

fied in the. Society of Automotive Engineers
Aeronautical Recommended Practice concerning
design-fault-failure analyses characteristic ofaerospace industry , processes used for the past2 decades. 107,108
6. The NRC encourages application of analyses todesign basis accidents and safety systems orboth. Once again, this is sometimes counterproductive to examining what factors really can leadto an accident. A false sense of security isdeveloped.
7. The performance of analyses by personnel within
the licensee's or vendor's organization seems
more appropriate to meeting some licensing requirement than deriving knowledge about hazards within the system; that is, analysis for thesake of analysis or certification, rather than aspart of the design process. This, of course, relates back to the form of the NRC requirements.

Somewhat extended discussion of the hazard
analysis issue has been provided here compared to123 1

other parts of this report. This is because hazard
analysis represents one key, if not the key, to safety engineering management deficiency at the NRC.
An effective hazard analysis effort over the life cycleof a system is the spine to which all body components of an accident prevention program are attached. Anticipating and controlling hazards at thedesign stage is just the beginning. Outputs fromproperly effected hazard analysis efforts are vital tomaintenance tasks, training, operational procedures,and knowledge in the mind of the system manager
as to the safety of his system. They form the basis
for meaningful system safety reviews.
In regard to managing the safety of a system, risk
management, as it is more generally known, is not
merely a matter of controlling probabilities of accidents as derived from analysis. Not only are there
uncertainties in the analysis process which are generally13,97,1
accepted both inside and outside theos but also management must balance
NRC,
three fundamental elements: performance (including
safety performance), cost, and schedule. It entails
judgment, but not just technical judgment. It also
requires value impact judgment in terms of economy
and public interest impact judgment in which theti me factor can become significant.
The objective is to take intelligent risks, not to
expect to simply accept them or reject them.llo
b. Safety Communications
If the hazard analysis process just described isthe fundamental analytical tool used in producing an
acceptably safe system, the area of safety communications becomes vital as both an input and output mechanism related to hazard analysis. Santayana said: "Learn from the mistakes of others, youwill never live long enough to make them all yourself." That is a precept that can aid the nuclear
power industry as well as any other, but only ifmeans are available and used to derive and exchange safety information effectively.
At the time of the TMI-2 accident, the NRC had
several ways to obtain operational data. They
ranged from the very broad based Licensee Event
Reports" through defects and noncompliance reports required under 10 C.F.R. 21, to Abnormal Occurrences (those unscheduled events which theCommission determines are reportable to Congressbecause of their significance from the standpoint of
In response to a
public health and safety).
Government Accounting Officereport examining
113
the NRC appointed
these systems earlier in 1979,
a task force to consolidate and improve the use of
these data. Their report was issued May 15, 1979,and contained numerous recommendations, theprincipal thrust of which involved more centralized
controls
and monitoring of the incoming informa115
114
An organizational change was then madetion. '
to form an "Office116for Analysis and Evaluation of
Operational Data."
From review of past attempted use of these systems, and notwithstanding thenew organization (which really has not yet begun to
get underway), the following problems appear toremain:1. The data base is extremely broad, ranging fromthe simplest failures through identification of significant hazards (some reportable, others not) tothe "abnormal occurrences." A priority system ofreporting and analysis is essential, a separatingof the wheat from the chaff, while maintaining acapability for analyzing the chaff for residual bitsof grain.
2. Human error reporting is vital, yet existing policies and procedures do not provide a path forthis to be accomplished anonymously or, within
li mits, with a guarantee of immunity from punitive
action. This form of incident reporting can be amore meaningful way of creating a safety awareness attitude (let alone identifying specific hazards) than any single thing management can do
117
once a system is in operation.
3. No effort thus far has been made to combine the
LER program results with other sources of information to form a center for known safety precedents, a single location within the NRC which
stores for ready retrieval the bitter lessons of accidents, incidents, or particular related studies ofthe past. The normal library system or even theextensive information storage program in use at
the NRC will not serve the precedent center
function unless a specific program is devised to
do so.
Closely allied to the above is a need for the NRC
to improve and maintain its ties with the safety technology community outside of the nuclear safety
field. Therein rests the knowledge of safety engineering and management techniques which canbenefit the NRC and the nuclear industry, and conversely can allow nuclear safety experience tobenefit others. Therein, too, are sources of accident and incident information whose lessons areapplicable to nuclear powerplant design and operation.
I n the course of this study, inquiries were madeof four professional societies that traditionally havebeen active in safety work and more specifically inrecent years, for some of them, system safety work.

• American Society of Safety Engineers (ASSE)• Human Factors Society (HFS)1232

• National Safety Management Society (NSMS)• System Safety Society (SSS)

sonnel will be taken based upon findings of the survey. Such surveys are best done by personnel withno axes to grind for or against the utility or whatever organizational segment is being examined.
This safety survey technique is obviously aderivitive of management surveys which, when done
properly, employ group dynamics as well as interviews to elicit and analyze information.
No use of this approach or encouragement to its
use was encountered in discussions with NRC personnel, although it was pointed out that, independent of the NRC, some of the utility corporate
offices performed station reviews and some vendors
accomplished readiness reviews of utilities. To
what extent, if any, these reviews were safety surveys as described above is not clear.

These societies were literally unknown to allsenior management personnel contacted in thisstudy. Membership by NRC personnel ranged fromzero in NSMS, to one in SSS on August 6, 1979,
and one in HFS, to a few in ASSE, assumedly in thehealth physics area.
Similarly, the Electronics Industry Association has
sponsored a System Safety professional committee
for many years, their G-48 committee. There is norecord that any NRC employee has ever been amember.
This is not to deny the importance of the technical liaison between the American Nuclear Safety
and the IEEE. However, neither of those organizations has been closely associated with safety engineering and management as known by the othergroups cited.
Another safety communications element exami ned during this study was the use of group dynami cs. This comes into focus in safety boards, committees, or councils and in the conduct of safety
design reviews, inspections, audits, etc. It was
found that except at the utilities, where plant safetycommittees were mandated by the NRC, the concept of organizational segments whose exclusive
charter was the review of safety matters on a routine basis was simply not applied. At the NRC,
design reviews tend to be done on paper and,
where groups assemble, it is usually on a broader
subject than safety. Typical of these would be highlevel staff meetings and meetings of the Regulatory
Requirements Review Committee. IE and NRR tend
to meet with licensees separately, thereby negating
the benefits of interoffice input.
I n the matter of large scale inspections, audits,and the like a spectrum of techniques is available
for applying group thinking to possible problem situations. At one extreme is an inspection-anotherblack hat situation-wherein a check is madeagainst existing requirements with censure or puni shment looming in the background. Formal reports
are made and an adversary process can and usually
does develop.

c. Safety Attitude Development
As noted earlier, the Presidential Commission investigating TMI was critical of the NRC's attitude toward safety. But accepting this criticism. whichmost NRC people seem to do, the question remains:
How can it be modified? Certainly, attitudes in people, individually or collectively, are the result of sociopsychologicalbehavioral
influences
too
numerous to mention, but with equal certainty such
i nfluences include work experience. Accordingly,
the statutory considerations, policy matters, andsafety management approaches discussed in thisreport thus far help explain the NRC attitude.
Change them, and perhaps the attitude will change.
Another dimension of safety attitude that can be
explored deals with specific programs and techniques available to influence NRC personnel or others in modern safety management matters. Four
separate approaches are identifiable:
1. Education-The process of teaching people tothink;
2. Training-The development of skills to performparticular tasks;
3. Indoctrination-The application of existing experience, education, and training to a new work environment;
4. Motivation-The enhancement of a person'scommitment toward a particular goal, sometimes
called awareness development.

At the other end of the spectrum is the safetysurvey concept-a white hat approach-sometimes
known as a staff assistance visit. Like inspections,these are performed by well qualified people, but
not in the formal sense of an inspection. Inquiry
may well go beyond the written requirements. It isdone on a nonadversary basis with findings
reported only to the senior one or two people of theorganization being surveyed, from whom a commitment is obtained that no punitive action against per-

These are not mutually exclusive, but the optimum methods to effect attitude changes throughthese approaches vary. For example education canbest be acquired in an academic environment usingcase studies rather than teaching machines which,however, have merit in training. Indoctrination may
1233be a standard program for all employees, but
motivation may require a more personal appeal because of the difference in individuals.
What was found at the NRC in these regards was
minimal safety education, training, indoctrination,and motivation programs-at least among seniorpersonnel. A significant number of predominently
NRR and RES personnel have attended the MIT nuclear safety technology courses. A relatively large
number of similar personnel have attended statistical reliability or probability analysis courses. A verysmall number of IE staff began attending MORT programs sponsored by ERDA-DOE about eighteenmonths ago. Only in this latter area was safety
management a specific topic in the curriculum.
Other nuclear safety engineering courses havebeen given at Catholic University, Georgia Instituteof Technology, Northwestern University, and the
University of Tennessee, among possibly others;
however, these have not been attended significantly
by NRC personnel.
Until it came up during the course of this study,
the Management Development and Training Office
was unaware of a graduate degree program in safety available in Washington, D.C., through the University of Southern California. Similarly, George Washi ngton University has been offering a System Safety
Course for nearly a decade. Review of theirrecords showed attendance of three people fromthe AEC in the early 1970s; none from the NRC.
There is no reason to believe any different results
would be found in examining the safety attitudedevelopment in the nuclear industry.
I n sum, the NRC and the rest of the nuclear
power community are blessed with extremely
technically qualified and motivated people. Their
exposure to safety attitude education, training, etc.,
has been miniscule in the overall sense of what
could be done. Even the MIT courses, which werevisionary at the time they were conceived by thel ate Dr. Thompson in the mid-1960s, are so
predominently engineering and science oriented thatsafety management principles are hard to recognize.
Contrast this to the DoD, NASA, and certain nonnuclear industries that not only provided a full rangeof safety attitude development programs beginning
as early as the mid-1950s, but also made themavailable to top level managers as well as nonmanagerial personnel.
d. Accident-Incident Investigation
Competent accident-incident investigation is a vital part of any accident prevention program. Only
by such an effort can the realities of operational use

of a system be fed back to allow evaluation of theengineering, operational, and management decisions
made earlier. It leads not only to upgrading the system in question but also to the improvement of othersystems, whether currently operating or being
planned.
fororientedThis
purposesafetyaccident-incident investigations is different fromthose investigations whose objective is to determine
culpability or adherence to administrative requirements. The techniques used in a safety oriented investigation also differ somewhat from those conducted for enforcement purposes. In the former, arelative level of informality combined with party participation in determining the facts contrasts with thel egalistic, adversary process found in the latter. Any"black hat" investigation inhibits determination ofsome types of facts (for instance, human performance) and often extends the cost of the investigation significantly in both money and time.
Perhaps the most important aspect of a safety
oriented versus the enforcement oriented investigation, especially one conducted by a group otherthan line management, is the outsider's perceptionof an objective inquiry. For example, the successful
i mage of investigations conducted by the National
Transportation Safety Board is directly related totheir organizational separation from the Federal Aviation Administration, National Highway Traffic Safety
Administration, and others: Also, this aura of objectivity is enhanced significantly by making factual information public as soon as it becomes available
and is reasonably verified, and by widespread publishing of the total findings. Because of legal ramifications, enforcement investigations can rarely provide information as promptly and completely as the
public usually demands.
As noted in Subsection 4.d., the NRC did nothave a structured accident-incident investigation
plan in effect prior to TMI. The absence of statedsafety objectives of the investigations that wereconducted, combined with assignment of the investigative task to IE, resulted in only enforcement
oriented investigations of accidents and incidents.
Other deficiencies revealed in the NRC process, andtypified by the TMI accident, included:• There is no clear definition of authority, at least

as shown by the lack of authority exercised byi nvestigators in taking control of the investigation,
securing records, demanding prompt interviews,
and other such matters time-critical in any investigation.
• There is a dichotomy of job assignments within IE
whereby personnel are designated investigators
or inspectors. The investigators are not geared
to the technical aspects of plant operation, and

1234

•

•

•
•
•

the inspectors are not necessarily competent ininvestigation.
There is no organized way to obtain constructive
assistance from parties to the investigation (forexample, the organization of teams in particularinvestigative areas to which parties could contribute qualified personnel).
There is no obligation or motive for IE to gather
facts leading to questions about the adequacy of
the regulations; the process only determines
whether or not the licensee adhered to those inexistence.
Formal training of IE personnel in accident investigation has only recently begun and there is norecord of personnel from other offices participating in MORT or equivalent programs.
There is a lack of familiarity with and use of logic
diagrams in reporting the results of accidents.
No procedures exist to ensure the safety of NRC
employees on site at the scene of an ongoing
emergency.

IE is currently proposing policies and procedures
to correct these problems; however, because of
their current organizational charter, they are severely handicapped in any attempts to conduct both
safety and enforcement investigations. The very
fact that the Special Inquiry Group had to be called
i n to provide an independent investigation of theThree Mile Island accident is symptomatic of an
accident-incident investigation safety management
problem at the NRC. Granted, the magnitude of
public attention to TMI-2 may have been the triggeri ng force; nonetheless, the scope of the Group's inquiry would be difficult to assign within the existing
NRC organization and still have the results accepted
as being nonbiased.
e. Resolution of Perceived Hazards
As discussed earlier, the effectiveness of any
safety program is not measurable statistically withreference to accidents. Accidents are simply too
rare. Incidents provide a better data base but they
suffer from inability to control the subjective judgments inherent in the reporting of incidents. Another less well known index of safety program performance is the development of recommended action
following accidents or incidents and monitoring actions taken as a result. This can be referred to as
the "prevention of action failure" task.
The Incident Investigation Review Committee(II RC), mentioned briefly earlier, is a group that was
to bridge the gap between incident responses
described in NRC Manual Chapter 0502 and thedevelopment of codes, guides, and standards. Notethat incidents in this sense are occurrences of actual or potential hazard to public health and safety.
They could conceivably become "abnormal occurrences" upon designation by the Commission.
They also could be of no immediate threat or may
have relatively insignificant effects. In any event, theII RC was theoretically in a position to develop andensure appropriate corrective action following major
events.
The problem observed throughout all of these
programs thus far, however, is the lack of a consolidated system for logging and tracking corrective action recommendations whether action is taken orwhether it is decided no action is necessary. This is
not to say a given item cannot be researched andits disposition cannot eventually be learned. Whatis missing is good visibility of this vital safety
management factor.
This tracking requirement is not a new problem; it
was addressed at least by 1972 in a report entitled,"Evaluation of Incidents of Primary Coolant Releasefrom Operating Boiling Water Reactors," WASH
1260.
Another shortcoming was the lack of a defined
objective and approach to conducting special studies for analyzing data collectively; that is, beyond
the meaning of a given report. Many events, taken
singly, have little significance. When combined andexamined statistically or as a function of changes tothe norm of reported events, significant hazards thatmight otherwise not be seen can become visible.
f. Development of Emergency Procedures
I nvestigation of the TMI accident revealed little
direct input by the NRC into the development andevaluation of emergency procedures used in control
rooms. History has shown that this, too, is an area
to which safety technology should be applied.
Traditionally,
emergency
proceduresaredeveloped by designers and equipment operators.
They know the system extremely well but sufferfrom two common failings. First, they tend to makevalue judgments on how others should react under
given circumstances. Second, their experience
usually does not include exposure to a sufficientnumber of accidents or incidents to appreciate how
people will react during an emergency. There is adifference between what a person can do and whata person will do during an emergency.
Additionally, engineers who develop emergency
procedures tend to narrow their thinking to thosesubsystems for which they have design accountability. As TMI disclosed, the problems requiring emergency treatment, especially those involving human1235

action, can and usually do involve more than one
subsystem.
These are phenomena that safety specialists encounter continually during investigation, hence oneof the safety tasks is to be certain that the realworld experience with accidents and incidents is incorporated into operational emergency procedures.
g. The Safety Ombudsman Task
Even the most cursory review of policies andprocedures issued at the NRC over the past few
years pertaining to "differing professional opin66.119,120
i on"reveals a fundamental safety needwithin the organization: The ability of anyone tobring a concern about safety to the right people forconscientious attention, review, and disposition.
The recent NUREG-0567 120 is by far the mostcomprehensive statement of policy ever seen in thisregard, for which NRC management is to be commended.
It should be appreciated, however, that simply
advising people they have a right as well as a duty
to bring disagreements forward may not be enough.
First, interpersonal relationships that exist between
an employee and the supervisor may readily inhibit
following the authorized procedures. Second, theparty with the information may not be willing to identify himself, either in fear of retribution or because
he or she was the one at fault. Thus the desirabilityof an ombudsman function which, in safety matters,
sometimes becomes analogous to the role of Chaplain. Information providing ethical questions as to
how it should be handled, especially if the reportingi ndividual is at fault, is received in confidence.
I n any event, the availability of a person to hear
the safety concerns of others on a very private
basis is an integral part of safety management technology.
h. General Observations about Safety TasksThat specific tasks within the frameworkdescribed above are significant in the aftermath of
TMI is illustrated pointedly in the Lessons Learned
Task Force Final Report. Quite independently fromthe present study, that report detailed numerous
suggestions that fit this safety task logic. These are
i ndicated in the following summary, which are direct
quotes from the Lessons Learned Report showing
the task area into which they fit. The number refers
to pages in Reference 16.

• Safety Tasks (general)-"... the NRC staff must

give increased attention to the detailed methodsof obtaining improvements in operational safety"(pp. 2-3).
• Plans-'...the NRC [should have] an effective
plan to take the lead in articulating a coordinatedapproach and a generally accepted goal fortechnical qualifications for both onsite and offsite
personnel and for both normal and accident conditions" (pp. 2-5).
The approach of the licensing reviews shouldbe "integrated ... from event initiation throughconsequence mitigation" (p. A-16).
Need "Continuity of licensing cognizance andresponsibility
from initialplant licensing,throughout construction into operation" (p. A-16).
• Hazard Analysis-"The staff should initiate a systematic assessment of the reliability of the safetysystems in operating units and in the late stagesof construction using simplified fault and event
tree analysis" (p. A-13).
• Safety Communications-" ... staff safety reviews
may be too prescriptive in nature and do not promote awareness or incentive to pursue on abroader basis new areas of potential safety concern. ... the emphasis should be on system level
reviews" (pp. 4-5).
There should be an "annual workshop ... forexchange of information on operating experiences" (p. A-6).
"... assure that a mechanism exists throughwhich
l essons
learnedfromoperatingexperience ... are conveyed to the reactor operators" (p. A-11).
• Safety Attitude Development-"As part of the
training program for all licensed operators ... acourse should be conducted [to] include:(a) Safety Analysis(b) Probabalistic assessments(c) Current safety issues and recent significant
operating experience(d) NRC and industry responsibilities for safety" (p. A-5). " Assurance of adequate
operations experience and training for the
NRC technical review staff" (p. A-16).
• Accident-Incident Investigation-There is a needed "integration of the new NRC and utility programs for evaluating operating experience" (pp.
2-7).
There should be "an accident evaluation function within the Office of Nuclear Reactor Regulation" (pp. 4-5).
"The NRC staff should establish a mechanism
whereby ... operational errors are identified in

1236management approach is difficult to find which
would include relatively nontechnical matters suchas choice of site, emergency planning, and economi cs affecting the public interest. This is another way
of saying the NRC's approach to organization andmanagement has been too narrow and too imbalanced in the direction of high technology engineeri ng and scientific activities. The results have been
the inevitable voids that develop between subsystems and the lack of attention entirely to certain
other subsystems.
Symptomatic of this problem, too, is the physicaldispersion of the Washington, D.C., area NRC offices. This is an extremely serious adverse influence toward organizational cohesiveness. It was
described succinctly by one deponent as "unconscionable" and leads to the NRC's being "like manyagencies in one." 1

Licensee Event Reports ... should include provisions for protection of the privacy of the individual" (p. A-5).
Per NUREG-0578, "each licensee is now required to have an operations experience evaluation group" (p. A-11).
Establish a "designated Emergency Response
Team ... multidisciplinary..." (p. A-16).
• Resolution of Perceived Hazards-"Use of a formal procedure for followup on questions and requests from ACRS... " (p. A-16).

• Development of Emergency Procedures-The

emergency procedure review "practice [should]
be changed to provide for interdisciplinary
review ... as part of the operating license review
process" (pp. 2-6).

Still another point raised, at least by implication,sthequestion of who should perform these tasks.
iThis question will be addressed more in the next
section, Organization for Safety, but for the present
it is enough to say that qualifications and motivation,
not organizational position, of the people doing thework are the key ingredients. It follows that safetytasks should not simply be parceled out to exsisting
personnel without additional education and training
where necessary.

a. The Line (Decisionmaking) Organization
Given resolution of the question about the role of
the Commission versus the EDO versus the Officeheads, one matter remains when examining the line
or decisionmaking function within the NRC organization. It is the current difficulty in identifying the office or person making the decisions on a given project, as typified by any license application. As discussed in Subsection 3.e., this becomes a policy
matter to be considered at least at the Commission
level; however, without some matrix approach to organization which includes a relatively strong project
management function, the probability remains that
all factors important to safety will not be heard anddecided upon expeditiously.
This does not mean the highly competent technical personnel within the functional offices lose theirstatus in the decision process; rather they may haveto take things up the functional chain of command
to a higher level if they do not agree with the project
manager's decision. This would be the exception
rather than the rule among professionals. In a matrix organizaton, an overwhelming percentage ofdisputed issues are resolved at the project
manager-functional manager level.

7. ORGANIZATION FOR SAFETY
Organization for safety is analogous to safety
management as a whole in that it reflects certain
precepts shown by experience to encourage safety
effectiveness. Of course organization for safety canbe no better than the overall assembly of personnel
and resources into discrete organization segments
and management's fundamental division of all thework. For example, if an organization has fundamental flaws regarding decisionmaking, the organization for safety is just that much more limited fromthe beginning, and no amount of band-aid organization changes will produce significant improvements.
In this vein, several perceived NRC organization
shortcomings are presented prior to examining organization for safety itself. The first was discussed
earlier (see Subsection 2.c.), and involved the conflicting directions implicit in the statutes governing
the NRC. The second includes a lack of a systems
engineering approach during the licensing process.
As typified by the Division of Systems Safety being
limited to certain safety systems without a detectable integrating function elsewhere, NRR's technicallicensing effort tends to be fragmented. Then, toextend this problem another dimension, a systems

b. The Staff (Advisory) Organization
The staff function as used here is advisory,where the only authority a staff person has is his or
her ability to convince the decisionmaker of thecorrectness of the position. This is not to be con1 237

fused with the military chief of staff function in which
the chief and his subordinates may be delegateddecision authority, along with clout approaching thatof the superior, in certain matters.
To be effective, staff functions must report at rel atively high levels as a matter of communications
efficiency. They characteristically include areas ofexpertise which may not be needed in project oreven functional segments of the organization, at
l east at that particular time. They often represent
skills that extend across and are needed on an interdepartmental basis. For this reason, safety technology is usually seen being applied first as a staff
activity and later, if necessary, as a functional area
i n support of projects, as has been seen in othertechnical fields. Even when this occurs, however, asafety policy function is usually reserved at thehighest levels of management.
Within the NRC the safety staff function is provided in two ways, each with shortcomings of note.
The most obvious staff input for safety is the Advisory Committee for Reactor Safeguards (ACRS).
Generally successful and having made significant
contributions over the years, ACRS suffers from thesame narrowness of perspective in safety mattersas characterizes the entire NRC organization. This
becomes apparent when reviewing the backgroundsof the current members. 122 For example, no record
exists suggesting ACRS recognized the human factors engineering problem in licensing; it is not justcoincidental that no member of the ACRS has significant experience qualifications in this area. Also,
there is no record suggesting recognition by ACRS
that safety management problems existed at the
NRC before TMI, at least as compared with themagnitude of reports since then. Whereas the same
reasoning may apply in explaining this as with thelack of attention to human factors engineering, amuch more logical explanation rests with ACRS notchoosing to interpret its charter to criticize NRC
management.
The second major safety staff advisory source isfrom the current NRR Office Chiefs and their key
subordinates. After all, they are usually experts in
one field or another; hence, they could serve in anadvisory capacity in their field. The potential conflictoccurs when the same people providing technicaladvice are making all the decisions. The check andbalance function of matrix program management isthereby lost. Recognition by upper management
personnel at the NRC of this potential conflict was
not apparent during this study.
Other offices, besides the program or functional
offices, are in a position to supply the necessary

staff input for safety, for example, the Office of Policy Evaluation (OPE), IE, or the Office of Research(RES). However, OPE does not seem to have this in
its charter nor does it have personnel trained insafety technology. IE has some potentially excellent
personnel in this regard, but tends to be overfocused on their inspection and enforcement roles.
RES similarly has potential, but the scope of theircurrent research efforts does not seem to include
safety technology as described herein.
I n any event, it remains a matter for the Commission as a matter of policy and the Chairman as chief
executive officer to effect the right balance between
line and staff inputs to safety. The line input isneeded to get a job done. The staff input is needed
to assure the job is done right. The combination of
the two produce a balanced and objective result.
c. Considerations Other than Line and Staff
While not usually strictly construed as organizational matters, three other considerations merit attention here. They can influence significantly theconventional internal workings of an organization.
First is the posture of one major office in relation
to others in resolution of safety issues. Reverting
once again to the benefits of group dynamics (plusthe fact that significant safety issues are rarely theprovince of a given office), some interdepartmental
safety organization is needed. Except for the Regulatory Requirements Review Committee (RRRC), no
sign of such an approach at the NRC has been evident.
Second is the need for some interagency approach to safety. This includes NRC participation insafety efforts being conducted by other members of
the nuclear power community, as typified by professional committee activity. It also includes participation with other government agencies in discussionsof safety management matters germane to all segments of the Federal establishment. Nothing likethis exists nor has it ever existed, except approximately fifteen years ago when President Johnson
mandated "Mission Safety 70," a coordinated effort
123
to reduce accidents involving Federal operations.
Third is the hard to describe informal organization
for safety, somewhat theoretical but ever so effective if it can be established. It requires identificationof specific personnel in all organization segments
who, for one reason or another, have a penchant for
promoting accident prevention. They are thevolunteers, and the work would not necessarily bepart of their job description. They would not be su-

1238pervisory personnel. They would be an informal
two-way communications link to structured safety
activities. They are the key to a safety motivatedwork force; get them on board and other tasks become much easier.
d. Advisability of a Separate Staff Safety
FunctionIf the safety management concept using thegrowing body of safety technology is recognized, anorganization question rises immediately. Should
there be a separate safety organizational segment
and, if so, how should it be integrated into the totalorganization structure? This question was considered only once in the past by either the AEC or
the NRC. An Operational Safety Branch existedfrom 1967 to 1972 in the Reactor Licensing Divisionof the AEC; however, as the title suggests, its assignment was basically limited to operational safety
matters. It had an oversight function which did notmeet with much favor in the entrenched line organizations. Also it became a matter of "turf conflict," touse a contemporary phrase, between the inspection
and regulatory offices. The branch evolved into the
Office of Operations Analysis from 1972 to 1975, but
was then disbanded. The view taken was that theentire function of the agency was safety oriented,
thus a separate safety monitoring organization
would be redundant.
When examining history in other fields, noticeably
in the aerospace industry, one finds this samequestion had been faced many times both insideand outside the government. A trend over the years
has been toward staff level safety offices, even inapplications where safety is "everybody's job." Forexample, what function is more safety dependent
than defying the laws of gravity during flight operations. Safety staff offices are used routinely in aviation agencies both at the engineering and operational ends of the life cycle spectrum.
The general trend towards specialized safetyfunctions notwithstanding, the matter should be approached with caution. The complexity of the total
task to be performed, the mores of the organization,
and above all the background and motivation of thepeople available are all determinants at least equali n importance to the applications of safety
management theory.
Even given the TMI induced proliferation of required safety tasks as discussed in this report, andthe implication that a separate organization segment
should be formed to handle them, does not negate

the possibility that these tasks can be performed insome format that does not scream "safety office." It
becomes a matter of total organization structure
and the fundamental right and need of management
to divide the work in the most effective way, given
its resources.
Principal among these resources are the people.
Indeed, most modern organizational theorists will
plead: "Build the organization around the people,"not simply insert people into some preordained organization chart cubbyhole. Of course, this issometimes difficult within the Federal Service.
If one is to apply safety technology, however,certain personnel classification factors should be
kept in mind. Safety as an occupational specialty isrelatively new, probably not more than 20 to 30
years old. An oversimplification exists by calling it a
specialty. It requires interdisciplinary skills because
the nature of accidents is interdisciplinary. Anotherway to look at it is that a safety specialist-one whocarries out the safety tasks-is a specialist only in
one thing, attitude, and that attitude is accident
prevention. He or she must be a generalist in
knowledge, requiring focus only to the extent needed to communicate with the technical experts in theparticular field of application. That field may be nuclear engineering; it might also be human factors,
management, law, communications, etc.
Particular care must also be taken not to confuse
safety technology with equivalent technologies ofreliability engineering or quality assurance. Tracing
the history of how these fields developed will reveal
distinguishable differences in attitude, techniques,and professional contribution. 124 Overlaps or interfaces occur, thus a generic category of "assurance
sciences" can be used to cover the lot. If specialization in safety technology is needed, apply it. Do
not just rename something else.

1239

8. CONCLUSIONS AND RECOMMENDATIONSThis assessment of the safety management posture of the NRC has revealed a classic paradox.
The mission of the agency and the intent of the persons attempting to carry out that mission focus
upon nuclear power reactor safety. Yet some of themost elementary attitudes and approaches to safety
as exercised in other agencies are not found in the
NRC.
It would be a gross oversimplification to assess
accountability for this condition only at the NRC. In
particular, the statutory base of the Commission has
invited authority and policy problems. Similarly, therole of the nongovernment nuclear energy
community-the utilities and their vendors-has
been passive, not dynamic and self-desciplined tothe degree required in management of a nuclear
reactor's highly complex technology.
The NRC, however, seems to have tolerated
known deficiencies in its enabling legislation. It has
permitted a narrowed span of attention to traditional
engineering and scientific areas of endeavor, to the
exclusion of modern systems management techniques such as systems engineering and the application of human factors and system safety technology. It has fallen into the trap of allowing risk assessment, which can never produce a meaningful
absolute quantified result, to mask the accident
prevention benefits available during an effective hazard analysis program. The NRC's project management was allowed to degenerate into what is reallyproject coordination, with management direction
emanating from a curious combination of functional,
committee, and legal inputs. Finally, the NRC's role
has been more oriented to prescriptive licensing ofa utility-putting a "Good Housekeeping Seal of Approval" on a proposed product-as distinguishedfrom a role of regulation which must include carefulmonitoring and control during the entire life cycle ofa nuclear facility.
That more TMI's have not occurred is effective
testimony to the apparent application of excellent
nuclear technology skills thus far. In fact, in retrospect, this is probably why the possibility of TMI-type
accident was not really appreciated by personnel at
all levels of the NRC. Whereas knowledgeable persons never promised perfect safety-and rightly
so-the superb record prior to TMI easily led to afalse sense of security in the minds of the vast majority of members of the nuclear power community.
Fortunately, the safety management shortcomings revealed in this study are not insurmountable.
Nor in the author's opinion are they of a nature
which would demand full correction prior to resumption of an aggressive program of development andoperation of nuclear powerplants in the UnitedStates. The "hyper" level of management's safety
awareness based upon TMI and actions currently
underway have combined to produce a much lower
probability of an accident than existed before TMI.
At least on an interim basis following recognition ofcritical hazards in a given industry, the level of safety goes up even though the hazards themselves
have not diminished. Such is the effect of safety
awareness and motivation on the people involved.
To resolve the safety management problems revealed in this study and to effect relatively long term
1240

i mprovement in nuclear power safety, the following
recommendations are offered:

1. A National Nuclear Safety Program Plan should
be developed and approved by the President, aplan reflecting clearly the nuclear safety philosophy and policy to be followed and the allocationof nuclear safety roles among all segments of thegovernment. A specific proposal for this planshould be developed by the NRC in coordination
with other Federal and State agencies, representatives of the industry, and committees of theCongress.
2. Complementary to the above, the President
should establish a Federal Safety Policy Board toensure future cooperation among all Federal
agencies in exchanging and applying modem
safety technology.
3. The NRC should propose, and the Atomic Energy
Act of 1954 and the Energy Act of 1974 should
be amended, to:a. Establish the objectives of nuclear power
safety beyond simple health and safety ofthe public to include protection against
economic loss and maintenance of a viablenuclear power capability in the public interest.
b. Retain the five-person Commission configuration but provide the Chairman unequivocal decisional authority in matters other than those of an adjudicatory nature
brought before the Commission. Further,
unfettered freedom of expression of views
to the public for each of the Commissioners
should be provided. Alternatively, if a single
administrator form of organization ischosen, provide that administrator with atruly independent Safety Review Board that
ensures adequate incorporation of thesafety technology and principles as
described in this report.
c. Require both high order administrative andnuclear technical qualifications for appointment of the senior official of the NRC andfor the first two levels of line authority
thereunder.
d. Establish minimum qualifications for theother Commission or Board Members to reflect a cross-section of public perception of
the effect of nuclear energy upon the
Nation's needs. Where familiarity with nuclear energy technology is not implicit intheir background, require a specific nuclear
technology indoctrination program prior toassuming an active agency role.

e. Remove the existing constraints on organizational structure of the NRC (the specific
Office designations), yet emphasize theneed for program direction with effective
check and balance between project andfunctional areas.
f. Rename the Advisory Committee for Reactor Safeguards to Advisory Committee for
Reactor Safety and modify its purpose toprovide inputs broader than nuclear engineering. Require particular and balanced
qualifications among the membership.
4. The NRC should adopt and announce the following as matters of policy:a. That "safety" in its application within NRC isa positive, nonconstraining force in thedevelopment of a viable U.S. nuclear power
capability and includes the protection of the
public against significant economic loss aswell as protection against injury.
b. That risk assessment in nuclear safety is afunction not only of probability but also
severity of the hazard, whereas risk
management entails balancing system performance (including safety characteristics)
with costs and timeliness as required in the
public interest. Risk assessment is therefore only an input to the risk management
decision process.
c. That NRC requirements must be consideredminimum standards by the nuclear industry,
which has accountability beyond the NRC's
to implement reasonably available advancements in safety engineering and management.
d. That NRC's regulatory role is much broader
than licensing, and its scope includes all
facets of the nuclear energy production
system over the life cycle of that system.
e. That prosecutorial discretion will be exercised to effect a meaningful balance
between enforcement of rules to ensure
their accomplishment and yet encourage
close cooperation with industry in communications to prevent accidents.
f. That the fundamental organization precept
to be applied throughout the NRC is project
management in which the project manager
shall have day-to-day decisional accountabili ty, with functional organization management being held accountable concurrently
for the technical adequacy of the decision.
g. That during the course of accident-incident
investigations, all factual information will be
1241

made available to the public as soon as it
has been reasonably verified as long as it
does not materially inhibit the ongoing investigative tasks.
5. In accord with the foregoing policy changes, the
NRC should accomplish the following in regard toorganization matters:a. Examine and modify the NRC organization
as required to assure application of safety
technology in the staff sense as described
i n Subsection 6 of this report as well as toassure that safety is implicit in the functionsof all offices.
b. Establish a human factors technology basewithin the functional organizations.
c. Modify the existing program -project offices and restaff as necessary tostrengthen their decisional capability andauthority.
d. Establish a headquarters accident-incident
investigation team, reporting to the Commission, with procedures and authorities toinvestigate particular events for purposes ofsafety, but not enforcement.
6. Additional actions by the NRC are suggested asfollows:
a. A study should be made leading to incorporation of applicable safety engineeringand management features of DoD andNASA standards MIL-STD-882A and NASA
Manual NHB 1700.1(V3) into the NRC regulatory process. This includes particularly
the planning, system safety review, data
item submission, and configuration control
functions.
b. Develop and implement a Regulatory Guideor equivalent requirement to ensure adequate safety management at licensees andtheir vendors throughout all phases of theutility's life cycle.
c. A life cycle oriented hazard analysis program should be defined and imposed as arequirement upon all contributors, vendors
as well as utilities.
d. A human error reporting procedure should
be adopted, possibly as an adjunct to the
LER program, which will permit anonymous
reporting and reasonable immunity fromcensure by either the NRC or the person's
employer.
e. Develop a requirement for and otherwise
encourage the use of safety surveys or
staff assistance visits at utilities and theirvendors.

f. Develop a safety engineering and management attitude development program for all
levels of NRC personnel, utilizing optimized
education, training, i ndoctrination, andmotivation techniques. Include representatives of industry in each program to facilitate mutual safety policy understanding.
g. Develop a quality assurance program applied to the NRC operations with respect tolicensing of utilities.
h. Develop
i mplement
anandtraining
accident-incident
i nvestigation
course for NRC personnel who might become involved in IE or broader based investigations. Consider the current MORT
program at least as an interim approach.
i. Encourage NRC personnel participation insafety activities conducted by other industries, to include seminar attendance, participation on professional committees, andmembership in professional safety societies.
j. Develop a specific nuclear safety information or known precedent center within the
NRC, programmed and coded in such amanner as to be able to respond quickly
and effectively to any inquiry concerning
lessons learned from previous accidents
and incidents.
k. Develop a nuclear safety technology handbook or text which includes not only nuclear engineering matters but also humanfactors and other considerations germane
to a total system safety effort.

I.

Establish a single location for all greater
Washington area offices.

Establishing a priority for the above recommendations is a difficult task at best. Countless othersuggestions have also surfaced as a result of the
TMI and, in fact, actions are probably alreadyunderway in many areas discussed here and elsewhere. Accordingly one final recommendation is inorder. A coordination office should be establishedto log, examine, track, and publicize the dispositionof all recommendations made by responsible parties
who have investigated TMI. Once this is done, theCommission will be in a much better position to takewhatever action it chooses and to regain at least
some of the credibility lost in the eyes of the public.
It is suggested specifically, however, that thoserecommendations
noted above dealing withaccident-incident investigation should be implemented on very high priority. Unwanted events
have the unfortunate characteristic of not waiting
until people are ready for them.
9. EPILOGUE
Man has been characterized as the only creature
with an infinite capacity for making trouble for himself and we seem to be fully exercising that capacity today.... Perhaps it is not too much to hopethat the same qualities which have enabled him totriumph over the destructive forces of nature will
enable him to master those he himself has created 125

1242

REFERENCES AND NOTES'President's Commission on The Accident at Three
Mile Island, "The Need for Change: The Legacy of TMI,"
October 1979, at 7-21.
2
Id. at 13.
3
As an example, see 49 C.F.R. 830.2 for definitions
applicable to aircraft accidents.
4
Heinrich, H. W., "Industrial Accident Prevention," 4thEdition, McGraw-Hill Book Company, Inc., New York,1959. (Previous editions in 1931,1941 and 1954.)
5
C. O. Miller, "The Role of System Safety in
Aerospace Management," Masters Thesis, University ofSouthern California, January 1967, at 8.
6
C. O. Miller, "Some Principles of Aviation Accident
Hazard Prevention, January-February
Prevention,"
1976, at 17-21.
7 U. S. Department of Defense, "Military Standard, System Safety Program Requirements," MIL-STD-882A, June
28, 1977.
8
U.S. Department of Defense, "System Safety
Engineering and Management," DoD Instruction No.
5000.36, December 6,1978.
9National Aeronautics and Space Administration, "System Safety," NHB. 1700.1(V3), March 6, 1970.
10
Warren H. Donnelly, "Nuclear Power: The Three Mile
Island Accident and Its Investigation," Congressional
Research Service Issue Brief No. 11379035, April 19,1979.
11
Electric Power Research Institute, "Analysis of Three
Mile Island-Unit 2 Accident," NSAC-1, July 1979.
12
USNRC, "TMI-2 Lessons Learned Task Force Status
Report and Short-Term Recommendations" (NUREG0578), July 1979.
13
USNRC, "Investigation Into the March 28, 1979 Three
Mile Island Accident by the Office of Inspection and
Enforcement" (NUREG-0600), August 1979.
14
USNRC, "Report to the Director, Office of Inspection
and Enforcement on Lessons Learned from Three Mile
Island" (NUREG-0616 DRAFT), October 10, 1979.
15
President's Commission on the Accident at Three
Mile Island, "Report of the Office of Chief Counsel on theRole of the Managing Utility and Its Suppliers," October
31,1979.
18
USNRC, "TMI-2 Lessons Learned Task Force Final
Report" (NUREG-0585), October 1979, at 3-1.
17
USNRC, Special Inquiry Group, "Three Mile Island: A
Report to the Commissioners and to the Public," January
1980.
18 Government Accounting Office, "Opportunities to
Improve the Effectiveness of the Nuclear Regulatory
Commission." In preparation; draft forwarded for comment at NRC October 19, 1979. Restricted to official use.

22

The Energy Reorganization Act of 1974, Public Law
93-438(88 Stat. 1233).
23
Section 161(i)(3) of the Act of 1954 states the Commission is authorized to prescribe such regulations "togovern any activity pursuant to this Act, including standards and restrictions governing the design, location andoperation of facilities used in the conduct of such activity,
i n order to protect health and to minimize danger to lifeand property." This comes in sequence within Section
161(i) after authorization to "protect Restricted Data" and"guard against the loss or diversion of any special nuclear
material."24
See 5 above, at 8.
25
USNRC, Memorandum from Leonard Bickwit, Jr.,
NRC, to Commissioners, NRC, Subject: Adequate Protection of the Health and Safety of the Public, October 18,
1979.
28
U.S. Department of the Air Force, "USAF System
Safety Programs," AF Regulation 800-16, June 6, 1979.
27
George T. Mazuzan and Roger A. Trask, "An Outline
History of Nuclear Regulation and Licensing, 1949-1979,"
April 1979.
28
BIack's Law Dictionary, 4th Ed. Rev.
29
The Energy Reorganization Act of 1974 as amended.
Sec. 205(f) Public Law 95-209 (91 Stat. 1482),1977.
30
Swain, Alan D., "Preliminary Human Factors Analysis
of Zion Nuclear Power Plant" (NUREG 76-6503), October
1975.
31
MORT, an acronym for Management Oversight Risk
Tree: An approach to safety management based upon
extensive use of logic diagrams. For a complete understanding of the concept, including its applications, refer to
32-47 below.
32
U.S. Atomic Energy Commission, "MORT: The
Management Oversight and Risk Tree" (SAN 821-2),
February 12, 1973.
33 EG&G Idaho, Inc., "Occupancy-Use Readiness
Manual-Safety Considerations" (ERDA-76-45-1), September 1975.
34
EG&G Idaho, Inc., "Reported Significant Observation(RSO) Studies" (ERDA-76-45-5), March 1976.
35
Energy Research and Development Administration,"Accident-Incident Investigation Manual" (ERDA-76-20),
August 1, 1975.
38 Energy Research and Development Administration,"A Contractor Guide to Advance Preparation for Accident
Investigation" (ERDA-76-45-3), March 1976.
37
EG&G Idaho, Inc., "MORT User's Manual" (ERDA76/45-4), November 1976.
38
EG&G Idaho, Inc., "Standardization Guide for Construction and Use of MORT-Type Analytic Trees" (ERDA76-45/8), February 1977.
39
EG&G Idaho, Inc., "Safety Information System Guide"(ERDA 76-45/9), March 1977.
4°EG&G Idaho, Inc., "MORT: A Safety Management
Program Developed for ERDA" (ERDA 77-38), March
1977.
41
EG&G Idaho, Inc., "Safety Information System Catal oging" (ERDA 76-45/10), May 1977.

t9USNRC, Contract with System Safety, Inc., NRC-17-

79-452, dated May 16,1979.
20USNRC, Office of Public Affairs Release No. 79-104,"Attorney Mitchell Rogovin Named to Direct NRC's Special Inquiry Into Three Mile Island Accident," June 14,
1973.
21
The Atomic Energy Act of 1954 as Amended, Public
Law 83-703 (68 Stat. 919).

1243

42

EG&G Idaho, Inc., "Risk Management Guide" (ERDA76-45/11),
June 1977.
43
EG&G Idaho, Inc., "Safety Considerations in Evaluation of Maintenance Programs" (DOE 76-45/12), March
1978.
44
James E. Davidson, "Practical Applications of MORT
Concepts," Sandia Laboratories. Presented at the Professional Conference of the American Society of Safety
Engineers,
Washington, D.C., June 20,1978.
45
EG&G Idaho, Inc., "Events and Causal Factors
Charting"(DOE 76-45/14), August 1978.
46
EG&G Idaho, Inc., "Management Factors in Accident
and Incident Prevention (Including Management Self
Evaluation Checksheets)" (DOE-76-45/13), August 1978.
47
EG&G Idaho, Inc., "Applications of MORT to Review
of Safety Analysis" (SSDC-17), July 1979.
48
Gerard Bruggink, "The Safety Role of Regulatory,
Corporate and Personal Initiatives in the 80's." Presented
at the U.S. Government Accounting Office Conference on
Transportation Issues of the 1980's," Washington, D.C.,
June 19-20,1979.
49General Accounting Office, Letter from P. B. Staats,
Comptroller General of the U.S., to Hon. Richard S.
Schweiker, Subject: Analysis of NRC's program forli censing nuclear power plant operators, dated May 15,
1979.
50
The Energy Reorganization Act of 1974 as amended,
Sec. 201, Public Law 94-79 (1975).
51
USNRC, "The Safety of Nuclear Power Reactors( Light Water-Cooled and Related Facilities" (WASH 1250),
Final
Draft, July 1973.
52
Letter from H. W. Lewis to Cong. Udall, Subject:
Suggestion for an Independent Accident Investigation
Activity,
dated November 23, 1977.
53
10 C.F.R. 50, "Domestic Licensing of Production andUtilization Facilities" (Title 10, Chapter 1, C.F.R.-Energy),
at 50-50.
54
T. J. Thompson and J. G. Beckerly, The Technologyof Nuclear Reactor Safety, the MIT Press, Cambridge,
Mass.,
1977, at 2.
55
The NRC's Office of General Counsel believes court
i nterpretations of the NRC's authorities leave room for theCommission to treat economic factors "provided ... publichealth and safety is consistently treated as a paramountconsideration." However, AEC and NRC pronouncements
to the contrary were also cited. See also reference 25,
above.
56
USNRC, Deposition of Roger Mattson, Director, Division of Systems Safety, NRC, by NRC/SIG, September
24,1979, at 167.
57
At a meeting of the Society of Air Safety Investigators,58Washington, D.C., June 22, 1979.
Letter from Chairman Hendrie, NRC, to Gong. Udall,
Subject: Creation of a nuclear accident review board,
August7,1978, at 1.
59
Metropolitan Edison Co., "Preliminary Safety
Analysis Report, Three Mile Island Nuclear Station-2," asamended through October 27,1971, at 1-1a.
80
Metropolitan Edison Co., "Final Safety Analysis
Report, Three Mile Island-Unit 2," Docket No. 50-320 asamended through November 8,1978, at 1.1-1.
N. G. Rickover, Statement Before the Subcommittee
on Energy Research and Development, House Committee

on Science and Technology, Washington, D.C., May 24,
1979.
62
USNRC, Deposition of Albert P. Kenneke, Acting
Director, Office of Policy Evaluation, NRC, by NRC/SIG
October 22, 1979, at 49.
3
B USNRC, Notes of Interview of Joseph M. Hendrie,
Chairman, NRC, by C. O. Miller, NRC/SIG, October 29,
1979.
84
USNRC, "Identification of Unresolved Safety Issues
Relating to Nuclear Power Plants (NUREG-0510), January
1979.
65
USNRC, Memorandum from J. S. Creswell to J. F.
Streeter, Subject: Conveying New Information to Licensing Boards, Davis Besse Units 2 & 3 and Midland Units 1& 2, dated January 8, 1979. The memo is an account ofa precursor event occurring at the Davis Besse plant
which, if adequately acted upon, had great potential for
preventing
the TMI accident.
66
USNRC, "A survey of Policies and Procedures Applicable to the Expression of Differing Professional Opinions: For Comment" (NUREG-0500), July 1978.
87
USNRC, "Standard Format and Content of Safety
Analysis Reports for Nuclear Power Plants, LWR Edition"(NUREG-75/094), (Reg. Guide 1.70), September 1975.
68
Essex Corporation, "Human Factors Evaluation ofControl Room Design and Operator Performance at Three
Mile Island-2," December 1979, at 23.
89
USNRC, Minutes of the 234th Meeting of theAdvisory Committee on Reactor Safeguards, Washington,
D.C., October 45,1979, at 202.
70
See 16 above, at 1-2.
71
Although a Federal Safety Council existed someyears ago, its scope of activity did not encompass work
as fundamental as indicated here. Presently, it is merelyan Advisory Council to the Secretary of Labor on mattersrelated only to Federal worker occupational safety andhealth.
72
U.S. Department of Labor, Federal Advisory Council
on Occupational Safety and Health, Articles of Organization, January 1975.
73See 5 above, at 25.
74
USNRC Manual, Chapter 0502, "NRC Incident
ReponseProgram."75
USNRC, "Recommendations Related to the Brown's
Ferry
70 Fire" (NUREG 0050), February 1976.
See 68 above, at 23.
77
USNRC, "Reactor Safety Study: An Assessment of
Accident Risks in the U.S. Commercial Nuclear Power
Plants" (WASH 1400), October 1975.
78
Letter from Gong. Udall to Chairman Hendrie, Subject: Suggestion for improved accident analysis andprevention,
dated January 2,1978.
79
Letter from Stephan Lawroski, ACRS, to Cong.
Udall, Subject Establishment of a quasi-judicial board for
accident analysis, dated June 8,1978.
80
Letter from H. W. Lewis to Cong. Udall, Subject:
Suggestion for an "NTSB" for reactor safety, dated
October 4, 1978.
sletter from Chairman Hendrie, NRC, to Cong. Udall,
Subject: Nuclear accident review board, dated November
28,1978.
82
IE's obligation is to "gather information in order toassist in NRC's independent evaluation of effects of the1244

i ncident to assess licensee compliance with plans andprocedures." This is not investigation in a safety sense.
See 74 above, at 13.
Letter from Chairman Hendrie, NRC, to NRC Commissioners, Subject: Letters pertaining to independent
accident
investigation activities, dated December 5,1978.
84
USNRC, "Licensing Project Manager's Handbook,"
revised, December 30, 1977.
National Aeronautics and Space Administration,"Facilities Assurance Plan," proposed chapter in theNASA
Safety Manual 1700.1, June 21, 1979.
86
See 69 above, at 227.
87
1d.at 238.
88
Prosser Torts, 4th Ed., Sec. 78.
89
U.S. Department of Commerce, "Draft Uniform Product Liability Law," Sec. 106 and 107., F2Federal Register
Vol.9044, No. 9, January 12,1979, at 3006.
Federal Tort Claims Act, 28 U.S.C.A., Sec. 2680(a).
91See
16 above, at 3-1.
92
"American National Standard Administrative Controls
and Quality Assurance for the Operational Phase of
Nuclear Power Plants," ANSI N 18.7-1976.
93
USNRC, "Quality Assurance Program Requirements( Operation)"(Reg. Guide 1.33), February 1978.
94
USNRC, "Safety Evaluation Report for TMI-2"( NUREG0107), September 1976.
95
USNRC, Deposition of Stephan H. Hanauer, Assistant Director, Plant Systems, by NRC/SIG, September 25,
1979,
at 225.
96
USNRC, "Reactor Safety Study: An Assessment of
Accident Risks in U.S. Commercial Nuclear Power Plants"(WASH1400), (NUREG-75/014), October 1975.
97
USNRC, "Risk Assessment Review Group Report to
the U.S. Nuclear Regulatory Commission" (NUREG/CR400), September 1978.
98 See 16 above at 4-2.
99 U.S. Atomic Energy Commission, Letter from Donald
F. Knuth, Subject: Criteria for Determining Enforcement
Action and Categories of Non Compliance with AEC
Regulatory Regulations-Modifications," Washington, D.C.,
December
31,1974, at 1.
100
0SNRC, Letters from Max W. Carbon, ACRS, to
Chairman Hendrie, Subject: NUREG-0600, Investigation
i nto the March 28, 1979 Three Mile Island Accident by
Office of Inspection and Enforcement," dated November
14, 101
1979.
C. O. Miller, "Hazard Analysis and Identification in
System Safety Engineering," 1968 Annals of the
Assurance Sciences. New York: ASME, 1968.
102
USNRC, "Standard Review Plan for the Review of
Safety Analysis Reports" (NUREG-75/087), September
1975.
103
USNRC, Letter from S. H. Hanauer, NRC, to Dr. William Brand, Subject: Use in the licensing process offailuremodes and effects analysis, dated June 19,1979.
104
P.Rubel, "Bonsai; Cultivating the Logic Tree for
Reactor Safety," Proceedings 1975 Annual Reliability and
Maintainability Symposium.

105 Joseph R. Penland, "A Formulation of Risk Assessment and Allocation," Proceedings 1975 Annual Reliability

and Maintainability Symposium.

"Westinghouse"Reference Safety

Nuclear Engineering Systems,
Analysis Report" (RESAR-411),

1245

October 1976, and Amendment 11, December 1977, at
6.3-53.
107
Society of Automotive Engineers, Aerospace
Recommended Practice, "Design Analysis Procedure for
Failure Mode, Effects and Criticality Analysis (FMECA),"ARP 926, September 15,1957.
108
Society of Automotive Engineers, Aerospace
Recommended Practice, "Fault/Failure Analysis Procedure,"
ARP 926A, November 15, 1979.
109
S. H. Hanauer and P. A. Morris, "Technical Safety
I ssues for Large Nuclear Power Plants." Presented in
Geneva,Switzerland, September 16, 1971.
110
Willis M. Hawkins, "The Challenge to Take Intelligent
Risks," Aeronautics and Astronautics, July/August 1979,at 36.
m
USNRC, "Instructions for Preparation of Data Entry
Sheets for Licensee Event Report (LER) File" (NUREG
0161),
July 1977.
n2
USNRC, "Abnormal Occurrence Procedure." NRC
Manual Chapter 0212.
13
t U.S. Government Accounting Office, "Reporting
Unscheduled Events at Commercial Nuclear Facilities:
Opportunities to Improve Nuclear Regulatory Commission
Oversight," EMD-79-16, January 26, 1979.
114
USNRC, Donald K. Davis et al., "NRC Task Force
Report on Operational Safety Data Analysis and Evaluation,"
May 15,1979.
115
USNRC, "Recommendations on Operational Data
Analysis and Evaluation of Nuclear Power Plants (Task
Force),"SECY 79-371, May 15,1979.
116
USNRC, "Status Report-Office for Analysis and
Evaluation of Operational Data," SECY 79-371A,
November 21,1979.
117 Federal Aviation Administration, "Aviation Safety
Reporting Program" (Advisory Circular 00-46B), June 15,
1979. Attention is called to the highly successful Aviation
Safety Reporting System underwritten by the Federal
Aviation Administration but directed, in the interests ofobjectivity, by the National Aeronautics and Space
Administration. This project has proven highly beneficial
in illuminating otherwise hidden flaws in the aviation system and has surmounted numerous attitudinal and legal
problems implicit in human error reporting programs.
118
U.S. Atomic Energy Commission, "Evaluation of
Incidents of Primary Coolant Release from Operating Boiling Water Reactors" (WASH 1260), October 30, 1972, at
32-35,
39, 44.
n9
USNRC, "Free Flow of Internal Information andViewpoints,"
Announcement No. 209, February 11, 1976.
120
USNRC, "Proposed Policy and Procedures forDiffering Professional Opinions" (NUREG 0567), October
1979.
121
See 62 above, at 42, 58.
122
5. Lawroski and D. W. Moeller, "Advisory Committee on Reactor Safeguards: Its Role in Nuclear Safety,"
Nuclear Safety, July-August 1979, at 388.
t23
U.S. Department of Labor, "Report to the President,
Mission Safety-70." Washington, D.C., September 1965.
124
5 above, at 54.
125
Jerome D. Frank, "Galloping Technology: A New
Social Disease," ETC, Vol XXV, No. 1, March 1968.

V SIG DEPOSITIONS AND INTERVIEWSWITNESSABRAHAM, Karl
ACKERMANN, Norbert
ACRS Members
ADAMCIK, Robert
AHEARNE, John
ALLENSPACH, Fredrick
AMYOT, Dennis
ANDERSON, Donald
ANDERSON, John
ANDERSON, Thomas M.
ANGELA, John
ARNOLD, Robert
BAKER, Robert,
Commander
BARRETT, Lake H.
BA UNACK, Walter
BEERS, Marshall
BILLS, Matthew
BLOSSER, Thomas

DATE

POSITION AND ORGANIZATION
Public Affairs Officer, IE-Region I, NRC
President, Technology for Energy Corp.
ACRS
Region III Director, FDAA, HUD
Commissioner, NRC
Technical Reviewer, Quality Assurance
Branch, DPM, NRR, NRC
Regional Director, Emergency Planning,
CanadaPrincipal Inspector, Vendor Section
Branch, IE-Region IV, NRC
Refueling Coordinator and Acting Quality
Control Manager at ANO, Arkansas Power& Light
Manager, Nuclear Safety Dept., Nuclear
Technology Division, Westinghouse
Project Manager, DPM, NRR, NRC
Vice President, Generation, GPUSCWhite House Communications Agency

9/24/79
10/25/79
10/6/79
10/25/79
10/12/79
9/12/79
12/11-12/79

Section Leader, Environmental Evaluation
Branch, DOR, NRR, NRC
Reactor Inspector, IE-Region I, NRC
Group Supervisor, Nuclear Training, Met Ed
Assoc. Deputy Asst. Administrator, EPA
Director, Office of Emergency Preparedness,
Cumberland Co., PA
124 7

9/7/7911/28/79
11/28/79
9/17/79
9/24/79
11/19/79
8/28/79
10/11/79
8/14/79
6/27/79
8/14/79WITNESSPOSITION AND ORGANIZATIONBORES, RobertRadiation Specialist, IE-Region I, NRC

BOYER, Robert
BRADFORD, Peter
BRETTHAUER, ErichDirector, Emergency Mgmt. , Lebanon Co., PA
Commissioner, NRC
Director, Nuclear Radiation Assessment
Division, EMSL, EPA, Las Vegas
Technical Reviewer, DOR, NRR, NRC
District Manager, USPS, Harrisburg, PA
Shift Supervisor-Nuclear, TMI, Met Ed
Materials Transportation Bureau, U.S.
Department of Transportation
Deputy Adjutant General, PA National Guard

BRINKMAN, Donald
BROWN, Robert
BRYAN, Kenneth
CARRICKER, Wendell
CAR ROLL, Robert,
Brigadier General
CASE, Edson
CAVANAUGH, William
CHASE, Emery
CHERRY, Bernard
CHWASTYK, Joseph
COBEAN, Warren
COLGAN, PaulCOLLINS, Douglas
COLLINS, Harold
COLLINS, John
CONGEL, FrankCO RCORAN, Robert
CREITZ, Walter
CRESWELL, James
CRITCHLOW, PaulCROWE, Charles
DAM, Allan S.
DARROW, William
DAVIES, Sherwood
DAVIS, Bobby J.
DAVIS, Don
DAVIS, John G.
DAVIS, Sid

Deputy Director, NRR, NRC

DATE
8/22/79 &11/8/79
8/17/79
10/19/79
7/16/79
10/19/79
9/20/79
10/11/79
8/9/798/15/79
10/18/79
10/24/79
11/27/79

Vice President, Generation & Construction,
Arkansas Power & Light
8/13/79
DoD
10/23/79
Vice President, Corporate Planning, GPU
Shift Supervisor-Nuclear, TMI, Met Ed
10/11,30/79
Vice President, Project Operations Div.,
11/5/79
Burns & Roe
Program Coordinator, SBA Regional Disaster8/13/79
Program
7/18/79
Health Physics Inspector, IE-Region II, NRC
9/19/79
Asst. Dir. for Emergency Preparedness, OSP,
NRC
Chief, Effluent Treatment Systems Branch,
9/13/79
DSE, NRR, NRC
Section Leader, Radiological Assessment
9/25/79
Branch, DSE, NRR, NRC
Chief, Division of Radiation Control,
8/22/79
Dept. of Health & Mental Hygiene, Stateof Maryland
President, Met Ed
10/23/79
11/16/79
10/12/79
Reactor Inspector, IE-Region III, NRC
10 /15 /79
10/12/79
Governor's Press Secretary, PA
9/28/79
Nuclear Civil Protection Officer, PEMA
Project Manager, TMI-2, Burns & Roe
11/5/79
Senior Vice Pres., Research & Medical
12/18/79
Director, Wallace Labs., Division of
Carter Wallace, Inc.
Director, Bureau of Radiological Health,9/25/79
New York State
Supervisor, RAP team, DOE-Oak Ridge
8/10/79
Head of Task Force on Need for Systematic
8/22/79
9/23/79
Evaluation of Operating Information, NRC
Deputy Director, NMSS, NRC
9/11/79 & 9/13/79
9/12/79
Director of News, Washington Bureau,
NBC News

124 8

WITNESS
DEAL, L. Joe
DEDDENS, James
DENTON, Harold
DERIVA N, Michael
DIECKAMP, Herman
DIRCKS, William
DONALDSON, Dale
DOORE, G. Stanley
DORNSIFE, William
DOYLE, Larry
DUBIE L, Richard
DUNN, Bert
DUTRA, Ed
DVORCHAK, Bob
EBERSOL E, Jesse
EISENHOWER, Elmer
EISENHUT, Darrell
ELLIOTT, Norman
ENGL E, Leon
ESSIG, Thomas
EVAN, Maj. George
FABIA N, Blaine
FAIST, Fred
FAUST, Craig
FERGUSON, DaleFISHER, Eugene
FLOYD, JamesFOSTER, James
FOUCHARD, Joseph
FRALEY, Ray
FREDERICK, Edward
FRIESS, Robert
FRY, DavidFURRER, Robert
GAHA N, Edward
GALLINA, Charles
GARRETT, Ralph

POSITION AND ORGANIZATION

DATE

7/31/79
Chief, Environmental Protection andPublic Safety Branch, DOE
10/16/79
Manager, Project Management (Former Headof Engineering), B&W
9/19/79
Director, NRR, NRC
10/4/79 & 10/23/79
Requalification Instructor, Toledo Edison
10/10/79
10/3/79
President, Chief Operating Officer, GPU
Director, NMSS, NRC
10/1/79
7/13 /79
Radiation Specialist, IE-Region I, NRC
7/18/79 & 8/23/79
7/27/79
Meteorologist, NOAA, Departmentof Commerce
Nuclear Engineer, PA Bureau of Radiological
9/19/79
Protection
Northeast Bureau Chief, CBS News
7/25/79
8/22/79
Supervisor, Radiation Protection &9/21/79
Chemistry, Met Ed
10/4/79
Unit Manager, ECCS Unit, B&W
11/30/79
Bureau of Drugs, FDA
8/9/79Bureau Chief, Harrisburg, PA,
Associated Press
ACRS
8/10/79
Chief, Office of Radiation Measurement, NBS
7/2/79
10/11/79
Deputy Director, DOR, NRR, NRC
10/17/79
Manager, Training Services, B&W
8/9/79Project Manager, DPM, NRR, NRC
7/14/79
Section Chief, Fuel Facility & Material
7/18/79
Safety Branch, IE -Region III, NRC
Disaster Control Officer, PA State Police
8/30/79
8/28/79
Manager, Communication Services, Met Ed
10 /15 /79
10/19/79
Resident Engineer, TMI-1, B&W
Control Room Operator, TMI, Met Ed
9/11/79
Health Physics Technical Manager, Nuclear
10/8/79
Support Services, Inc.
9/21/79
Chief, Bureau of Radiation Protection, N.J.
State Dept. of Envir. Protection
9/25/79
9/13/79
Supervisor of Operations, Unit-2, Met Ed
8/22/79
Investigation Specialist, IE-Region III,
NRC
Director, Office of Public Affairs, NRC
9/17/79
Executive Director, ACRS
8/27/79
Control Room Operator, TMI-2, Met Ed
9/11/79
Technical Assistant to the Area Manager,
7/6/79
Brookhaven Area Office, DOE
8/27/79
Civil Defense Director, Perry Co., PA
Management Analyst, PA Dept. of Agriculture
8/24/79
Senior Supervising Nuclear Engineer,
9/26/79
Burns and Roe
Investigation Specialist, IE-Region I, NRC
9/14/79
9/18/79
FEMA

1249

WI TNES SGERECKE, Kenneth
GERUSKY, Thomas
GIB SON, Albert
GILINSKY, Victor
GILRAY, JohnGOSSICK, Lee
GOTTILLA, Salvatore
GRABER, William
GRAHAM, John
GREGER, Robert
GREGORY, Bettina
GRIER, BoyceGRIMES, BrianHAASS, Walter
HALLER, Norman
HALLMA N, Donald
HALPERIN, Jerome
HANAUER, Stephen
HARPSTER, Terry
HARTMAN, Harold
HAVERKAMP, Donald
HEISHMAN, Robert
HELL ESON, G. L.
HENDERSON, OranHENDRIE, Joseph
HERBEIN, JohnHE UBNER, Arthur
HEWARD, RichardHIGGINBOTHAM, Leo
HIGGINS, JamesPOSITION AND ORGANIZATION

DATE

9/17/79
Asst. Adminstration for Technical Support,
Region III, OSHA
Director, Bureau of Radiation Protection,
9/19/79
PA. Dept. of Environmental
Resources
9/25/79
Chief, Radiation Support Section,
9/26/79
IE-Region II, NRC
10/5/79
Commissioner, NRC
9/17/79
Technical Reviewer, Quality Assurance
Branch, DPM, NRR, NRC
9/28/79
Exec. Director for Operations, NRC
10/23/79 & 10/29/79
Senior Supervising Engineer in Instrumen9/17/79
tation and Control, Burns and Roe
9/6/79Manager of Radiological Control, Training& Planning, Electric Boat, Division,
Gen. Dynamics Corp.
9/26/79
Treasurer, GPU
9/25/79
Radiation Specialist, IE-Region III, NRC
9/26/79
8/6/79Correspondent, ABC News
9/28/79
Director, IE-Region I, NRC
10/12/79
9/18/79
Asst. Director for Engineering andProjects, DOR, NRR, NRC
Chief, Quality Assurance Branch, DPM,
9/19/79
NRR, NRC
10/11/79
Director, Office of Management &Program Analysis, NRC
10/4/79
Manager, Plant Performance Section, B&W
12/19/79
Deputy Director, Bureau of Drugs, FDA
9/25/79
Asst. Director for Plant Systems,
9/26/79
DSS, NRR, NRC
Reactor Inspector, IE-Region III, NRC
8/30/79
10/29/79
Formerly Control Room Operator,
TMI, Met Ed
9/12/79
Reactor Inspector, IE-Region I, NRC
9/18/79
8/23/79
Chief, Reactor Operations and Nuclear
Support Branch, IE-Region III, NRC
7/3/79President, Helgeson Nuclear Service, Inc.,
Pleasanton, CA
9/20/79
Director, PEMA
10/9/79
Chairman, NRC
9/19/79
Vice President, Generation, Met Ed
11/7/79
11/20/79
Director, Radiation Control, Dept. ofEnvironmental Protection, CT
9/25/79
Manager of Projects, GPUSC
Asst. Director, Division of Fuel Facilities
9/24/79
and Materials Safety Inspections, IE, NRC
9/13/79
Reactor Inspector, IE-Region I, NRC

125 0

WI TNES SHILBISH, John
HITZ, Gregory
HOLCO MBE, Edward
HOLMES, Ashley
HUNTER, Dorwin
HUNTLEY, Donald
HYDE, Richard
INGRAM, FrankISRAEL, Sanford
JACKSON, Leslie
JACO BS, Ralph
JAMGOCHIAN, Michael
JA NOUSKI, Michael
JONES, Robert
JORDAN, Edward
JUDD, Alfred
KARRASCH, Bruce
KAUFMA N, Nick
KEATO N, Robert
KEIMIG, Richard
KELLOGG, PaulKELLY, Joseph
KENNEDY, Richard
KENNEKE, Albert
KEPPLER, James
KERR, Vernon
KIRKPA TRICK, Donald
KLINGAMA N, Richard
KLINGLER, Gerald
KNOP, Richard
KOHLER, Joel
KO SIBA, Richard
KUEHN, CarlKUNDER, George

POSITION AND ORGANIZATIONSupervisor of Licensing, Met Ed
Shift Supervisor, TMI, Met Ed
Comptroller, GPU & V-P-Compt., GPUSC
Chief, Reports Group, ODRR, FEMA
Reactor Inspector, IE-Region III, NRC
District Manager, Coal Mine Safety & Health,Dist. 2, U.S. Dept of Labor, Pittsburgh
Senior Vice President, Hill & Knowlton
Asst. to the Director, OPA, NRC
Section Leader, Reactor Systems Branch,
DSS, NRR, NRC
Director, York Co. Emergency Management
OfficeManager, Instrument Services,
Rad Services, Inc.
Site Designation Standards Branch,
DSHSS, SD, NRC
Senior Rad. Chem. Tech., Met Ed
Supervisory Engineer, ECCS Analysis, B&W
Asst. Director for Technical Programs,
I E , NRC
Federal Regional Council
Manager, Plant Integration Unit, Plant
Design Section, Engr. Dept., B&W
Director, LOFT, EG&G of Idaho, Inc.
Manager of Systems Engineering, GPUSC
Section Chief, Reactor Operations &Nuclear Support Branch, IE-Region I, NRC
Section Chief, Reactor Operations &Nuclear Support Branch, IE-Region II, NRC
Principal Engineer, Plant Integration
Division, B&W
Commissioner, NRC
Asst. Director for Technical Review,
OPE, NRC
Director, IE-Region III, NRC
Chief, Telecommunications Branch, ADM, NRC
Reactor Engineer, Technical Programs,
IE, NRCManager of Plant Engineering, Reading,
Met EdSenior Reactor Inspection Specialist,
IE, NRC
Section Chief, Reactor Construction andEngineering Support Branch, IE-Region III,
NRC
Reactor Inspector, IE-Region III, NRC
Manager, Customer Service Dept., Nucl.
Power Generation Division, B&W
Warning & Communications Officer, PEMA
Unit-2 Superintendent Technical Support,
Met Ed125 1

DATE
9/5/799/12/79
9/26/79
8/29/79
12/30/79
9/10/79
8/15/79
9/28/79
7/31/79
8/14/79
10/8/79
9/10/79
9/19/79
10/3/79
9/11/79
11/7/79
10/3/79
9/26/79
10/10/79
9/14/79
9/28/79
10/2/79
10/2/79
10/22/79
8/24/79
8/15/79
10/18/79
8/30/79
11/7/79
8/23/79
8/24/79
10/16/79
9/20/79
8/13/79
9/18/79WITNESSPOSITION AND ORGANIZATIONManager, Procurement, Met Ed
Div. Superintendent, Harrisburg Div.,CONRAILLAMISON, Kenneth
operations officer, PEMA
Health Physics Engineer, Met Ed
LANDRY, Leonard
Manager, Mechanical Engineering,
LANE, Rick
Arkansas Power & LightFBILATHAM, Lee
Reactor Inspector, IE-Region I, NRC
LAZARUS, William
LEE, Byron
Vice President, Commonwealth Edison Co.
President, Duke Power Co.
LEE, William
Director, Lancaster Co. Emergency
LEESE, PaulManagement Agency, PA
Shift Engineer, Met Ed
LENGEL, Robert
WHP Radio-TV Newsroom
L ESTER, Martha
Director, Nuclear Power Division, EPRILEVE NSON, Milton
Director, RES, NRC
LEVINE, Saul
Industry Consultant
LEVY, Sol
Technical Engineer, Generation Division,
LIES, Melvin
Met EdAssoc. Project Manager, B&W
LIGHTLE, RobertSuperintendent, Admin. & Tech. Support,
LIMROTH, DavidMet EdSuperintendent, TMI-2, Met Ed
LOGAN, Joseph
Director of Reliability Engineering, GPU
LONG, Robert
York County Emergency Management, PA
LOT T, DorisLOUNSBURY, Roy, Colonel Director, Div. of Safety, Envir. andEmergency Actions, DOE
Pickard, Lowe and Garrick
LOWE, William
Office of General Counsel, NRC
MALSCH, Martin
DSE, NRCMARTIN, James
MATTSON, Roger
Director, DSS, NRR, NRC
KUNKEL, JamesLAGEMAN, A. G.

MAYERCHECK, Donald
MAZETIS, Gerald
McADOO, John
McCONNELL, JamesMcCONNELL, John
McCORMICK, FrankMcINTIRE, Daniel
McKEE, Kenneth
McNAMARA, Eugene
McWILLIAMS, Jim
MEHLER, Brian

Tech. Rep. Nucl. Filter Systems Div.,
Mine Safety Appliances Co.
Section Leader, Reactor Systems Branch,
DSS, NRR, NRC
Asst. Manager, Nuclear Safety Dept.,
Nuc. Tech. Div., Westinghouse
Manager, Technology Assessment andDevelopment, GPU
Asst. Associate Director for
Population Preparedness, FEMAGroup Supervisor, Technical Training,
TMI, Met Ed
GPUSCCommunications Services Dept., GPU
Chief, Div. of Forest Protection,
Bureau of Forestry, PA
Asst. Operations Superintendent, ANO
Unit-1, Arkansas Power & Light
Shift Supervisor, TMI, Met Ed

125 2

DATE

8/30/79
8/17/79

9/20/79
10/9/79
11/27/79
11/29/79
9/13/79
9/5/7910/5/79
8/16/79
9/27/79
10/11/79
10/24/79
9/4/799/6/799/27/79
10/24/79
10/3/79
8/30/79
10/9/79
9/12/79
10/4/79
11/20/79
7/5/7912/4/79
10/30/79
6/22/79
9/24/79
10/17/79
8/10/79
8/8/7911/28/79
9/14/79
8/13/79 &12/11-12/79
10/8/79
9/4/79
10/4/79
8/16/79
11/28/79
10/11/79
10/30/79

WITNESSMICHELSON, Carlyle
MILLER, FredMILLER, Gary
MINOGUE, Robert
MOLLOY, Kevin
MOSELEY, Norman
MULLEAVY, Thomas
MURRAY, Blaine
MURRAY, TerryMURRAY, William
MYERS, Melvin
NAGLE, Earl
NARROW, Lewis
NEELY, Donald
NEWBERRY, Scott
NIMITZ, Ronald
NITTI, Donald
NOOP, William
NOVAK, Thomas
NRR RADIATIONPROTECTION PERSONNELOBOLD, Charles
O'TOOLE, Thomas
OWE N, Warren
PATTERSON, David
POPE, Norman
PORCO, Richard
PORTER, Ivan
PORTER, Sydney
POTTER, Tom
PREWITT, Daniel
PRUCHA, R. J.
RAYMOND, William
REID, Robert

POSITION AND ORGANIZATIONDATE

Consultant, ACRS
Plant Nuclear Systems Engineer, PowerEngineering Division, Toledo Edison Company
Station Manager, TMI. Met Ed
Director, SD, NRC
Director, Office of Emergency
Preparedness, Dauphin Co., PA
Director, Div. of Reactor Operations
Inspection, IE, NRC
Supervisor, Radiation Protection, TMI,Met EdRadiation Specialist, IE-Region IV, NRC
Plant Superintendent, Davis Besse,
Toledo Edison
Vice President, Communications, GPUSC
Formerly Office of Asst. Administrator
for R&D, EPA
Vice President, Group Manager, Construction
Division, United Engineers
Reactor Inspector, IE-Region I, NRC
Senior Radiological Inspector,
9/26/79 &IE-Region I, NRC.
Technical Reviewer, DSS, NRR, NRC
Radiation Specialist-Reactor Health Physics,
IE-Region 1, NRC
Engineer, B&W
West Virginia News Editor, UPI, PA
Chief, Reactor Systems Branch, DSS, NRR, NRC
NRR, NRC
Commanding Officer, Group 1100, Civil Air
Patrol, Reading, PA
Reporter, Washington Post
Senior Vice President, Engineering andConstruction, Duke Power Company
Chief Occupational Safety BD, DOE
Superintendent of Operations, Oconee 1-2-3,
Duke Power Co.
Filtration Engineer, Mine Safety
Appliances Co.
Instrumentation & Control.Engineer,
TMI-2, Met Ed
President, Porter-Gertz Consultants
Pickard, Lowe & Garrick
Asst. Director for Disaster Services,
Eastern Field Office, ARC
Food Safety and Quality Service, USDA
Reactor Inspector, IE-Region I, NRC
Chief, Operating Reactors Branch No. 4, DOR,
NRR, NRC
125 3

9/6/79
10/11/79
9/20/79
10/29/79
9/26/79
9/21/79
9/25/79
9/27/79
9/20/79
9/25/79
9/26/79
10/22/79
8/31/79
10/4/79
8/1/799/25/79
9/20/79
9/25/79
10/12/79
8/15/79
11/2/79
11/21/79
10/11/79
8/20/79
7/31/79
10/19/79
8/27/79
10/18/79
9/12/79
7/31/79
10/29/79
10/25/79
10/30/79
10/5/79
6/20/79
9/25/79
8/21/79
10/12/79
8/27/79

WI TNES S

POSITION AND ORGANIZATIONREILLY, Margaret

Chief, Div. of Environmental Radiation,
Bur. of Rad. Protection, State of PA
Deputy Director, Non-Metallic Materials
Lab. at Marshall Space Flight Center, NASA
Site Manager, TMI, B&W
Press Secretary & Special Asst. to the
Attorney General, Dept. of Justice,Commonwealth of PA
Deputy Director, DPM, NRR, NRC
Supervisor of Operations, TMI-1, Met Ed

RIEHL, Wilbur
ROGERS, Leland
ROSENFELD, Stephan
ROSS, Denwood
ROSS, Michael
ROY, Donald
RUETER, Don
RUHIMAN, William
SAGE, JamesSANDMAN, Roger
SCHAEDEL, Edwin
SCHAEFFER, Ivan
SCHEIMANN, Frederick
SCRANTON, William
SEARS, JohnSEELINGER, JamesSELDOMRIDGE, Howard
SEYFRIT, Karl
SHAPAR, Howard
SHEPHARD, GarySILVER, Harley
SIMPSON, Richard
SMITH, George
SNIEZE K, JamesSPANGLER, William
STAHLE, Carl
STELLO, Victor
STERN, FredSTERNBERG, Daniel

STOHR, JohnSTOLZ, John
STONE, JamesSTOREY, James

Engineer, B&W
Director, Technical & Environmental
Services, Arkansas Power & Light
Reactor Inspector, IE-Region II, NRC
DOE, Pittsburgh
Deputy Director, Office of Governmental
Affairs, USDA
Site Operations Engineer, TMI, B&W
Regional Managing Director, Philadelphia,
ICC
Shift Foreman, TMI-2, Met Ed
Lt. Governor, Pennsylvania
Technical Reviewer, Environmental Evaluation
Branch, DOR, NRR, NRC
Unit-2 Superintendent, Technical Support,
TMI, Met Ed
Communications Services Dept., Met Ed
Director, IE-Region IV, NRC
Director, OELD, NRC
Correspondent, CBS Network News
Project Manager, DPM, NRR, NRC
Director, Bur. of Regulation of Rates &Policies, PA. Insurance Dept,
Chief, Fuel Facility & Material Safety
Branch, IE-Region I, NRC
Director, Div. of Fuel Facility & Materials
Safety Inspection, IE, NRC
Manager, Plant Startup Services, Nuclear
Power Generation Division, B&W
Project Manager, DPM, NRR, NRC
Director, IE, NRC
10/10/79, 10/11/79 &Vice President, Products, Services &Development, Combustion Engineering
Section Chief, Reactor Operations Branch,
IE-Region V, NRC
Section Chief, Fuels Facilities andMaterials Safety Branch, Region I, NRC
Chief, LWR Branch No. 1, DPM, NRR, NRC
Reactor Inspection Specialist, IE, NRC
Supervisor of Security, Met Ed
125 4

DATE
9/19/79
8/8/798/10/79
10/11/79
8/16/79
9/28/79
9/18/79
10/30/79
10/15/79
11/27/79
9/6/798/22/79
8/9/79
10/11/79
9/24/79
9/11/79
11/23/79
10/11/79
8/14/79
9/5/79
10/3/79
9/4/79
10/1/79
7/25/79
7/23/79
8/16/79
10/11/79
9/24/79
10/16/79
8/9/799/12/79
10/30/79
10/26/79
8/3/799/7/798/16/79
10/16/79
11/9/79

WI TNES S
STREETER, JohnSUTER, Simeon
TAMBLING, Thomas
TAYLOR, JamesTENNILL, Major
TERPILAK, Michael
THOMPSON, Dudley
THORNBURG, Harold
THORNBURGH, Richard
TOOLE, Ronald
TROFFER, George
TSAGGARIS, Alexis
VARGA, Steven
VASSALLO, Domenic
VELEZ, Peter
VOLLMER, Richard
WALDMAN, Jay
WALTERS, Frank
WARD, E. Grant
WASHBURN, BeverlyWEISS, Bernard
WEISS, Seymour
WELCH, Emmett
WE NSLAWSKI, FrankWILBURN, Robert
WILLIAMS, JamesWILLIAMS, Ronald
WILLIAMSON, Craig
WILSON, JackWILSON, JamesPOSITION AND ORGANIZATION
Section Chief, Reactor Operations andNuclear Support Branch, IE-Region III, NRC
Emergency Planning Officer, Bureau of
Maintenance, PA. Dept. of Transportation
Reactor Inspector, IE-Region III, NRC

DATE
9/26/79
8/22/79
8/22/79
8/23/79
10/5/79
10/1/79
7/27/79
8/31/79
9/21/79
9/7/79Manager of Licensing, B&W
Public Affairs Officer, PA National Guard
Chief, Standards and Regulation Branch,Div. of Compliance, BRH, HEW
Acting Deputy Director, IE, NRC
Director, Div. of Reactor Construction
Inspection, IE, NRC
11/23/79
Governor, State of Pennsylvania
Unit Superintendent, Units 1 & 2, Homer City
9/26/79
Power Plant, Homer City, PA, GPUSCManager, Generation Quality Assurance, Met Ed
8/28/79
Supervisor, Station Maintenance, Titus
7/18/79
7/24/79
Station, Met Ed
8/8/79Chief, LWR Branch No. 4, DPM, NRR, NRC
8/15/79 & 8/16/79
Asst. Director for Light Water Reactors,
9/5/79
DPM, NRR, NRC
Radiation Protection Foreman, TMI, Met Ed
9/19/79
9/21/79
Director, TMI-2 Support and Acting Asst.
Dir. for Systematic Evaluation Program,
DOR, NRR, NRC
10/12/79
Executive Asst. to the Governor, PA.
10/2/79
Supervisory Engineer, Plant Performance
Services, Operating Reactor Group(Customer Svc.), B&W
Senior Project Manager, B&W
10/17/79
9/5/79Reactor Safety Researcher, Univ. of Calif.,
Los Alamos Scientific Laboratory
9/17/79
Sr. Technical Operations Specialist, Exec
Off. for Operations Support, IE, NRC
Section Leader, Reactor Safety Branch, DOR,
9/5/79
NRR, NRC
Deputy Secy. for Admin., Dept. of Health,
8/29/79
Commonwealth of PA
12/4/79
Chief, Reactor Radiation Safety Section,
9/25/79
9/26/79
IE-Region V, NRC
9/19/79
Secretary of Budget & Administration,
Commonwealth. of PA
Nuclear Preparedness Officer, Ohio Disaster9/20/79
Services Agency
10/9/79
Senior Consultant, Generation Div., GPUSC
Deputy Director, PEMA
9/28/79
10/12/79
Director, Boise Interagency Fire Center, Bur.
9/11/79
of Land Management, Dept. of the Interior
Executive Director, PA. Turnpike Commission
8/17/79
125 5

WI TNES S

POSITION AND ORGANIZATIONWILSON, Richard

Director, Technical Functions, GPU

WOLZEIN, Tom
WOMACK, Edgar
WOOD, James

Producer, NBC News
Manager of Plant Design, B&W
Assoc. Deputy Director, Office ofGovernmental Affairs, USDA
Pickard, Lowe and Garrick
Senior Reactor Inspections Specialist, IE,
NRCCommanding Officer, Capitol City Cadet
Squadron, Group 30, Civil Air Patrol
Director, Water Reactor Research, EG&G of
Idaho, Inc.
Radiation Specialist, IE-Region I, NRC
Director, Nuclear Safety Analysis Center,
Electric Power Research InstituteSupervisor of Training, Met Ed
Shift Supervisor, TMI, Met Ed

WOODARD, Keith
WOODRUFF, Roger
YARLETT, Earl
YBARRANDO, Lawrence
YUHAS, Gregory
ZEBROSKI, Edwin
ZECHMAN, Richard
ZEWE, William

125 6

DATE
8/29/79
10/8/79
7/26/79
10/15/79
8/9/796/20/79
8/9/798/21/79
9/26/79
7/18/79
9/27/79
9/14/79
9/11/79

VI COMPARISON OF THE SIG

RECOMMENDATIONS IN VOLUME I
WITH THOSE OF THE PRESIDENT'S
COMMISSION AND THE NRR/NRC
LESSONS LEARNED TASK FORCEINTRODUCTION

This appendix provides a comparison of the threesubject sets of recommendations to provide a general cross reference as to where recommendations
in similar subject areas might be found. No attempt
is made to characterize the nature of the recommendations. The purpose of this presentation is toprovide a quick overview of the scope of recommendations for each, as well as page references forthese recommendations.
The purpose of this is to provide an easy reference to the exact wording and context of a particular recommendation. The Special Inquiry Groupmakes no representation as to the completeness ofthese references; this analysis is provided only as
an aid to the reader, not as a substitute for reading
and fully understanding the source documents.

The source documents used in the preparation of
the following table are:1. Special Inquiry:
Three Mile Island: A Report to the Commissioners
and to the Public, Volume I.

2. President's Commission:
Report of the President's Commission on the
Accident at Three Mile Island.

3. Lessons Learned:(ST)TMI-2 Lessons Learned Task Force
Status Report and Short-Term Recommendations, NUREG-0578.
(LT)Lessons Learned Task Force Final Report,
NUREG-0585.

1257

For the Special Inquiry and the President's Commission Reports only the principal, clearly identified
recommendations are referenced in the table. No
attempt was made to reference other important
recommendations that may be found in:
1. The supporting text of the referenced
documents;
2. Documents containing differing opinions,such as those of the President's Commission;
3. Other documents, such as various staff
reports of the President's Commission.

Furthermore, the Lessons Learned documents
contain numerous recommendations of varying
importance. Judgment was used to identify the onespresented here. The attempt was to identify thosewhich in our view are of comparable importance tothe recommendations presented in Volume I of theSpecial Inquiry Report and in the President's Commission Report.

IDENTIFICATION OF RECOMMENDATIONS BY SUBJECT AREA
SpecialI nquiryArea of Recommendation
A. General
1. How Safe is Safe Enough?

91, 116
1 51
92,93
91, 15492, 146

2. Oversight Over the NRC
3. Public Education
4. Moratorium or Suspensionof Licensing Reviews
5. Statutory Base92

B. Evaluation of Operating Experience
1. Basic Responsibility

9799

2. Office of Analysis and Evaluationof Operating Data (AEOD)
3. Inspection of Plants
4. Institute of Nuclear PowerOperation (INPO)

1 00, 101
97, 110

C. Onsite Personnel and Procedures
1. Training

1 05

2. Technical Expertise

1 06

E. NRC Organization
1. Single Chief Executive
2. Consolidation of Resources
Devoted to Operating Reactors
3. Independent Nuclear Safety Board
4. Advisory Committee on Reactor
Safeguards

Lessons
Learned-LT A1561-

Page numbers

62
77, 79
64

-

66,68
73
66

LT 4-6,
A10, A13
LT A-1,
3-2
LT A-8LT 2-463,70
71

LT Al, 5,
6, 8;
ST 12
ST 13;
LT A5, 7
LT A8
LT A 7, 9,
1 0; LT 2-5;
ST 13

66,67
68

69

1 06
146
Vol. II

69

107, 108
110

-

ST 13
-

115-11799, 11761-

LT 4-5

3. Station Manning
4. Operating Procedures
D Industry-Wide Technical Resources
1. Data and Analysis Centers
2. Industry-Wide Consortium

President's
Commission

118, 119
119
1258

62
62

-

Special
I nquiryArea of Recommendation

119
1 20
1 20
1 21

5. Project Management
6. Periodic Manager Reassignments
7. Staff Training
8. Transfer of Non-Health and Safety
Responsibilities
9. NRC Office Consolidation
1 0. Office of Research

2. Control Room Design

3. NRC Emergency Response
4. Radiological Monitoring

H. Overhaul of the Licensing Process
1. Advisory Committee on Reactor
Safeguards
2. Ex-Parte Rule
3. One-Step Licensing Process
4. Atomic Safety and Licensing Appeal
Board
5. Rulemaking
6. Office of Public Counsel
7. Intervenor Funding
8. Standardization
9. Regulatory Requirements Review
Committee
1 0. Bases for Safety Reviews

61
63

-

LT A16-

1 27

72

LT A12,
13
LT A11,
13

130,131
1 30-133

1 34-136
137

64
64, 76,
77
63
63, 77-

LT A16-

1 40

62

LT A16

65
66
63
-

-

1 28

G. More Remote Siting and Improved
Emergency Planning
1. More Remote Siting
2. Emergency Planning

Lessons
Learned'

63

117
-

F. Human Factors Engineering
1. Instrumentation

President's
Commission
Page

63

1 41
1 41
1 40-142

65,66
65, 66

1 48, 150,

63, 64,72,73

LT A14,15, 16
3-1, 2;
ST A45155
Vol. II75
74, 75

-

1 57
157
-

78
78, 79
79

-

1 64
164

-

69

-

1 27, 128
Vol. II

72

Many

1 06, 110Vol. II64, 6869

LT All;ST 12,
A56

-

73

1 42
143
143, 144
144
146
151

I. Occupational and Public Health
1. Occupational Health
2. Public HealthJ. Information Made Available to theNews Media
1. Emergency Response Planning
2. Principal Spokesperson
3. Media Responsibilities

K. Disincentives to Safety
1. NRC Evaluation of Utility
Finances
2. Communication With Other Regulatory
BodiesL. Specific Hardware Modifications

M. Utility Organization
1. Management Responsibilities
N. Post-TMI Efforts
1. Cleanup and Disposal
1259

-

-

FINDINGS AND RECOMMENDATIONS IN VOLUME II
mendations and the page number(s) where that findi ng or recommendation can be found are listed
below. The reader is advised to refer to theappropriate sections of Volume II so that the meani ng and importance of particular findings and recommendations can be judged in context.

The three-part Volume II is an integral part of theSpecial Inquiry Group Report and contains many
detailed findings and recommendations. Some ofthese findings and recommendations are reflected inVolume I, but others are not. As an aid to thereader, the general subject of the findings or recom-

PART 1I. A. 1.c
I. A.2
I.A.3.aI. A.3.b
I. A.3.c

I. A.3.dI. B.1Category"

Subject

SectionLicensing and Regulatory System: An overview of its major
deficiencies in Assessing Reactor Safety
Relevant Staff Actions Taken Outside of the Adjudicatory
Process36

Quality Assurance

F

49,50

Technical Qualifications

F

Regulatory Requirements Review Committee

Licensing History of TMI-2

I. C.

Precursor Events

I nspection History at TMI Site

F&R
F
F

F&R

• Dopchie letter 4/27/71

FF• BEZNAU Incident 8/20/74

F• Reactor Safety Study 10/75

F• Michelson Report 9/77
• Davis Besse 9/24/77

F• Kelly-Dunn Memoranda 11/77

F
F• Pebble Springs ACRS Questions

F• Creswell Concerns 12/77

F• I srael-Novak Note 1/10/78• Rancho Seco - 3/78

I. E.

F
F

Generic Issues

Operating History of TMI Nuclear Station

I. D.

23-25

F

I. B.2I . B.3

F&R

Pages

F

• TMI - 3/78 Sternberg memo

Pressurizer Design and Performance: A Case Study
I ncentives to Begin "Commercial Operation"

F = Findings (or Conclusions)
R = Recommendations

1260

F

F&R

F&R

40,44
55

57,58

104-105114
126

130, 135-138
140

141, 142
143, 144

148, 149
1 55, 156
161

164

171-172
173

175
176

198-199

204, 241-247

Category*

Pages

Releases

F&R

341-342

Environmental Monitoring

F&R

395

Design Considerations in Radiation Protection

F&R

Radiation Protection Procedures

F&R

Radiation Protection Training

F&R

II.B.5.b

I n-Plant Monitoring and Instrumentation

F&R

429

II.B.5.bPersonnel Dosimetry

F&R

432

Subject

SectionPART 2

I I.B.1.aPrincipal Findings and Recommendations Related to Radioactive

I I.B.2

Release Pathways and Mechanisms

I I.B.3
II.B.4

II.B.5.b

1I.B.5.b

I I.B.5.b
11.B.5.b

II.B.5.b
1I.B.5.b
II.C.1

II.C.1.b

F&R

Dose Assessment and Health Effects

Management and Organization-Radiation Protection

F&R

Respiratory Protection

F&R

Responsibility of NRC and Utility for Radiation Protection

F&R

Deficiencies in the Plant: Revision of Design Basis
Accidents; Use of Human Factors
Primary System Deficiencies

R

407,408
411

417,419421

423,424430
438

447,448• Anticipatory Reactor Trip

F&R

454

• Reactor Pressure Control System

F&R

455,456• PORV

F&R• Pressurizer Level Instrumentation

F&R

F&R

• Surge Line Loop Seals

F&R• Reactor Coolant Pump Control• Natural Circulation

F&R
F&R

• Remote Venting Capability
II.C.1.cF366,368• Leaks in the Reactor Coolant System

Deficiencies Related to Engineered Safety Features

F

455
456
457

457,458
460
460
461

• Reactor Building Isolation

F&R

461

• Shielding of Engineered Safety Features

F&R

463

• RB Hydrogen Concentration Control• High Pressure Injection (HPI) Bypass• HPI Controls

F&R
F&R
F&R
F&R

• Core Barrel Vent ValvesF• Lack of Hot-Leg Injection Capability

1 261

462
463,464
464
465

465

Section

Subject

Category*• Adequacy of Debris Protection for the Reactor Building
Sump

F

465

F

467

• Emergency Feedwater Actuation and Control

F&R

468

• Condenser Hotwell Control

F&R

472

• Disturbance Analysis Systems

F&R• Diesel Generator Lockout• Decay Heat Removal System Not Designed for Operating
I I.C. 1.dPressures

Deficiencies Related to Secondary Coolant System• Condensate Polisher
II.C.1.e

I I.C. 2.b

I nstrumentation and Plant Data

• I nstrument Failures

I nterpretation of Accident SequenceCore Damage Estimates from Fission Product Release from Core..

1I.C.2.e

How Close to a Meltdown-Consequences of Core Melt at TMI

1I.D
II.E

Hydrogen Production, Removal Hazard

Alternative Accident Sequences-Summary of Findings

F&R

Human Factors

F
F
F
F
F

466

471

485
486

522,524
527
535
536

553-558• Operator Errors

F

580-581• Emergency Procedures

F

597• Control Room Design

F• Operator Training
II.F

F&R

F&R

1 I.C.2.c

II.C.2.dPages

F• Recommendations

R

593

603-604
612-613

Environmental and Socioeconomic Impacts

F&R

I I I. A.2

Plant Operations Response

F&R

852-854

III.A.4

I ndustry Support

F&R

891-892

Management Overview

F&R

PART 3

III.A.3
III.A.5
III.A.6

III.A.7

11 I.B.3.a

IIt.B.3.b

F&R

Radiological Emergency Response
Reporting of Critical Information

F&R

Radiation Emergency Plan

F&R

Findings re: management N RC emergency response
Evacuation Decisions

126 2

F
F

644-645873,874
911

920
930

977-978985

Section

Category*

Subject

Pages

R

986-989

F&R

1 007-1009

Sheltering and Evacuation Advisories

F&R

1017-1018

Evacuation Planning Before and During the Accident

F&R

1 024-1027

11I.C.6

Other Protective Actions Considered By Officials

F&R

III.C.7

Radiological Monitoring Efforts

F&R

1033-1034

11I.C.B

I nstitutional Communications During the Accident

F&R

1043-1044

1 II.C.9

Technical Support for the Plant

F

1 045-1046

III.B.3.c

NRC Emergency Response

II I.C.3

Federal and State Authorities and Responsibilities

II I.C.4
11I.C.S

Summary of Findings and Recommendations re: Federal andState Emergency Response• Root Cause

F&R• Overall Institutional Coordination

F&R• Siting• Overall Emergency Planning• Evacuation• Radiological Monitoring Efforts• Physical Communications

II I.D• Comparison with the President's Commission
News Media Interactions

1263

1046-1047

1047

F&R

1048-1049

F&R

1049-1050

1047-1048
1049

F&R

1050

F&R

1050-1051

F&R

1073-1075

F&R• The Act of Communicating

1046-1051

F&R

F&R

• Other Protective Actions

1038-1039

F

1050

1051

I NDEX
Volume II has many sections where there is substantial overlap of facts, analyses,

findings, and recommendations contained in other sections. Such repetition was, to al arge extent, unavoidable, because the report was generated by six task groups working
substantially independently. However, each had areas of inquiry that of necessity
overlapped those of one or more other task groups. Also, areas of intentional overlap
exist because a particular event (such as the decision to advise the evacuation of pregnant
women and young children) might logically be seen in a somewhat different light by, forexample, the Governor of Pennsylvania and the Chairman of the Nuclear Regulatory
Commission. We believe that such a perspective is useful to the reader.
The purpose of this index is, for those subjects that are discussed substantively inmore than one location, generally to lead the reader to the various locations in Volume I I
where these discussions can be found. The purpose is not to provide a comprehensive,
extremely detailed, and highly cross-referenced indexing of all possible subjects. For
example, failure of the PORV valve to close is mentioned throughout the report (such as
i n all of the various chronologies), yet no attempt is made to reference all of these entries.
References are only provided to substantive technical evaluations of this valve failure.

126 5

Advisory Committee on Reactor Safeguards
CP Review Letter, TMI-2 106
General 3, 12, 144, 154, 161-164
OL Review Letter, TMI-2 107, 283
Alternative Accident Sequences, General 142, 163,551-571
Effect of Containment 569
Emergency Feedwater 561
Fuel Melting and Slumping 537
High Pressure Injection 558, 561
Loss of Offsite Power 568

Meltdown
How Close? 535
Phenomena and Consequences 536
PORV Block Valve 562
Reactor Coolant Pumps 564

Recriticality 568
Anticipatory Reactor Trip 453
Atomic Safety and Licensing Appeal Board 13
Atomic Safety Licensing Board
General 138, 163, 168-169
TMI-2 Initial Decision 76
TMI-2 Review 287-306
Authorities and Responsibilities for Emergency Response
Federal 1002-1004
Overview 1001
State, Local 1004-1007
Auxiliary Feedwater System (See Emergency Feed water
System)Babcock & Wilcox
General 146-149, 154, 157-161, 162, 169,
166-171, 174, 189, 200
List of NSSS Plants 273
TM 1-2 Support Effort 886
Beznau Incident, Precursor 140, 453
Borated Water Storage Tank 503, 843
Burns and Roe
TM 1-2 Support Effort 889

Charcoal (Carbon) Filter 344-347, 355-364, 705-710
Analyses 355-359,705-710
Application 346, 360-364
Specifications 346, 360-363
Suppliers 346, 360-362
Usefulness 347, 358-359, 363-364
Chronology
Accident Sequence 309-340, 647-704
Alternate Interpretation of Accident Sequence790-802

Chronology (Continued)
Emergency Response
Utility 809, 840, 845
Federal, State, Local 995-1001, 1204-1209
NRC 943-969
Hydrogen Bubble Concerns 1129-1152
Radiological Releases 725-735, 1058-1062
Commercial Operations
I ncentives to Begin 203-260
Commissioners
Emergency Response 933, 978, 987, 1087

Licensing Role 13
Communications 136, 145, 173, 1039-1043
Notification (See also Chronology) 1 41, 151,
155, 995-996, 1039, 1040
NRC 129, 977, 978, 987, 1121-1128
Technical Information Transfer 894, 1040
Telephone Problems 1041
White House Lines 1041

Condensate System
Malfunctions, General 468
Polisher 468
Condenser Hotwell Control 471
Construction and Operation, General 10
Construction Permit Review 67-77
TMI-2 67-77
TMI-2 ACRS Review 71
Containment (See also Reactor Building)
Dome Monitor Dose Rate 859, 995
I solation 461
Pressure Spike 500-501, 902-911
Control Rooms
Alarms 149, 577-580
Annunciators 589, 593
Color Coding 593-594
Computers 150, 585
Control Room Design 140, 155, 581-596
Mimicking Plant Systems 587, 595
Obstructed View 591
Operational Aids 612
Parallax, Instrument 589
Shift Manning 604
Task Analysis 601
Control Room Ventilation 410
Habitability 410
Radiological Considerations 410-411
Respirator Protection 429-430
Coordination, NRC and Other Agencies (See Emergency
Response-NRC)
Core Damage, General 154, 487-550, 803-805
Damage Before Three Hours 513, 741-755
I nterpretation of Data 506

Core Temperatures
I n-Core Thermocouples 98, 504-505, 898-902
Creswell, Precursor 164
1266

Davis Besse Incident, Precursor 149
Decay Heat Removal System 462
Decisions, Adjudicatory, TMI-2 287
DesignComparison of TMI to same vintage plants 109,
117, 273, 593
Defense-in-Depth 8, 109-110
Design Basis Accidents 18
General 183
Remote Venting Capability for the RCS 460
Review, NRR/IE Responsibilities 269
Specific Components

Emergency Planning ( See Plans, Emergency; Emergency
Planning, Radiological; General Emergency; Site
Emergency)
Emergency P lanning, Radiological 99, 851, 922
Organizational 368-395, 414-417, 1035
Performance 414-417, 1035-1038
Radiological Response 368-393, 383-395, 715-720,
857

Emergency Response, NRC
Management ofAgency Role 933, 974-976, 988
Commissioners (See Commissioners, Emergency
Response) 933, 973
Communications 894, 972, 987-988, 1121-1126
Deployment of Personnel 969-971, 1101, 1119
Headquarters 940-943, 971-972, 987, 1101-1120
Hydrogen Bubble 981-982, 1129-1152

Control Room Habitability 410
Decontamination Facilities 411
PO R V 452, 562, 827

Radwaste System 344-355
Sampling Lines 410-411
Sampling Room 410-411
Ventilating Systems 409-410
Diesel Generators 465, 823
Disaster Declaration 1002, 1004, 1006

Notification Procedures 969
Onsite Organization 969-971, 986-987, 1101-1114
Region 1969-970
National Academy of Public Administration
Report 1156-1163
NRC Role in Evacuation (See Evacuation, Recommendations by NRC)
Environmental Impacts, NonradiologicalAquatic Effects 643-644
Socioeconomic (See Socioeconomic Impacts)
Environmental Monitoring 368-393
Augmented 369-383
Post Accident 369-371
Pre-Accident 368-369
Environmental Monitoring Results 368-393
Aircraft 383-389
Analytical 389-395
Air 389
Foodstuffs 370-371
Milk 389-390

Dopchie Letter, Precursor 139
Dosimetry-Offsite 368-393
Estimate, Dome Monitor 424-425, 429, 895
Methods
Aerial monitoring 383-389, 715-716
Meteorological modeling 721-724

Sampling and Analysis 389-390
Survey, radiological 383-389, 711-714
Thermoluminescent Dosimetry 390-395
Population Dosimetry 395-399
Ad Hoc Dose Assessment Group 398
Analyses and estimates 398-401
Department of Energy 398
Metropolitan Edison Co. (Woodward) 399
President's Commission 398
Special Inquiry Group Calculations 399
Population Exposures, Routine 405-406
Medical 405-406
Natural Background 405
Dosimetry-Onsite 430-432
Analysis of Occupational Exposures 401
Special Inquiry Group Determinations 401
Survey, Radiological 711-714
Thermoluminescent Dosimeters 368-373

Vegetation 390
Water 390
Survey 383-389
TLD 390-395
Evacuation (See also Emergency Response, NRC)
AlertsFriday (30 March 1979) 1012
Wednesday (28 March 1979) 1010
I mpacts (See Socioeconomic Impacts)
Planning During TMI
Evacuation Times, Estimated 1021-1022
Evaluation of Preparedness 1021-1023
Federal 1020-1021
State and Local 1006, 1019-1020
Planning, Pre-TMI 1005-1006, 1018
Pregnant Women and Small Children Advisory
Decision 1011, 1013-1014
Lifting Advisory 1016-1017

Emergency Core Cooling System (See also High Pressure
Injection)
I nterruption after LOCA 87, 143, 150, 159, 189,
463
TMI-2 Licensing 87
Emergency Feedwater System 143, 149, 165-166, 174
Block Valves Closed 467, 578, 822
TMI-2 Licensing 100
1267

Findings and Recommendations (Continued)

Pregnant Women and Small Children Advisory(Continued)
Mass Care Centers 1016
Recommendations by NRC 1012

Agency Action 978-982, 1153-1155
Appropriateness 982-985, 1015
Sirens 1012
Facility Changes, NRR/IE Responsibilities 5, 16, 269
Federal Response, Agency-by-Agency Account 1165-1191
Findings and Recommendations
Emergency Response, Federal and State
Authorities and Responsibilities 1007
Communications, Institutional 1043-1044
Evacuation Planning 1024-1027
Evacuation-Sheltering 1017-1018
General 930
Protective Actions, Other 1033-1034
Radiological Monitoring 1038-1039
Summary 1046-1051
Technical Support, Plant 891, 1045-1046
Emergency Response, NRC
Agency Role 977-978, 988
Commissioners 978, 987
Communications and Equipment 977-978, 987
Evacuation and Other Protective Action 986
Headquarters 977, 987-988
Hydrogen Bubble 986
Notification Procedures 977, 988
Onsite Organization 911, 977, 986
Region 1977, 988

I ndustry Support 891
I nspection History at TMI-2 126
I nstrumentation
Radiation Monitoring System 395, 429
Thermoluminescent Dosimetry 395
Licensing Process, General 23, 104
NRC Radiation Protection Deficiencies 411
Radiation Monitoring Instrument Specification
429
Respiratory Protection 411, 430
News Media Interface at TMI 1073-1075
Operating History 126
Operating License Review for TMI-2 104
Plant Deficiencies
Condensate Polisher 471
Condenser Hotwell Control 472
Containment Isolation 461
Containment Sump Protection 465
Coolant High-Point Vents 460
Coolant Leaks 461
Coolant Pressure Control 455
Coolant Pumps 457
Core Barrel Vent Valves 465
Decay Heat Removal System 467, 853
Diesel Generator Lockout 465
Disturbance Analysis 484
Emergency Feedwater Control 100, 468
General 447
High Pressure Injection 104, 463-464
Hot Leg Injection 465

Hydrogen Control 462
I nstrument Failures 485
NSSS Transient Sensitivity 454
PORV 454
Pressurizer Level 456
Shielding and Leakage of ESFs 462
Surge Line Loop Seals 457
Precursors, Accident (See individual events

Relationship with Others 978, 985, 989
Emergency Response, Radiological 874
Emergency Response, Utility 854, 920, 970

I ndustrial Support 854, 891
Management Overview of TMI Unit 2 854
Plant Operations 854
Radiation Emergency Plan-Development andTraining 421, 423, 874, 927
Radiological Emergency Response 874-925
Reporting of Critical Information to the NRC,
March 28, 1979 911
General Radiological 342, 874
Generic Issues 55
Human Factors 53
Control Room Design 612
Emergency Procedures 613, 852
Operational Aids 612, 854
Operator Licensing 613
Operator Performance 613, 852, 854
Operator Selection 612
Operator Training 612, 613
Shift Manning 612, 613, 854
Simulator Training 612, 613

for specific findings)

Pressurizer Design 449
Quality Assurance 23, 49-50, 104, 920
Radiological Assessment 395-408, 874
Occupational Radiation Exposures 401-402
Personnel Dosimetry 430-432
Population Health Effects 401-408
Regulatory Requirements Review Committee 17, 40,
104-105
Socioeconomic Impacts 644-645
Support Systems
Carbon Filter Performance 366, 368
Radioactive Waste Treatment 366, 368
Radiological Release Pathways 366, 368
Ventilation System 366, 368, 411
Technical Qualifications of Utility 54, 104-105
126 8

I ndustry Support (Continued)

General Emergency, Declaration of 857, 1058-1059
General Public Utilities Service Corp 838, 914
Generic Issues, NRC Licensing Process (See also
Licensing Process and Safety Issues)
General 20, 50-55, 105
NRR/IE Responsibilities 19, 269
TMI-2 65

Requests by Met Ed and GPU 876
Babcock and Wilcox 886
Bums and Roe 889
I nspection and Enforcement, NRC Office ofGeneral 5, 136-137, 150, 164-171
NRR/IE Responsibilities 19, 269
Review of Procedures (See Procedures, IE Review)
I nstrument Air System 470
I nstrumentation
Accident, to follow the course ofGeneral 173-175, 472-483
TMI-2 Licensing 95
Failures 485

Health Consequences and Effects, Radiological 401
Cancer 401-407
Fatal 406
I nduction Probability (risk factors) 402-403

Non-fatal 407
Genetic (Teratogenic) 404
Somatic 401-404
High Pressure Injection System (See Emergency
Core Cooling System)
Human Factors (See Control Rooms, Operators, Pro-

cedures, Training) 87, 104, 139-140, 144-149,
157, 161, 167, 463, 558, 561, 820, 829
Hydrogen Bubble
AP Hydrogen Bubble Story 1067
Calculation of Bubble Size 530, 757-762
Chronology of Bubble Concerns (See also Chronology,
Emergency Response (NRC)) 534,1129-1152
Federal Agency Support 1045
Hazards, Potential
Explosion in Reactor Vessel 535, 981-982
I nhibition of Natural Circulation 458
I ndustry Support 888
Removal 533
Hydrogen, General 102

Accounting 5quConcentration Control 102, 461
Production 527

Flow Recovery, Makeup 486
I ncore Thermocouples 504, 898
Neutron Detectors, Self-powered 504
PORV Position 175
Pressurizer Level 103, 449, 456
Qualification and Use 472
Qualification, Environmental 472
Self-Powered Neutron Detectors 504
Temperature Indication Range 486
Reactor Vessel Level 98
Israel-Novak Note, Precursor 172

Kelly-Dunn Memos, Precursor 157

Legislation Since TMI 1210-1212
Liability 203, 1005, 1007

Licensee Event Reports
NRR/IE responsibilities 271
TM 1-2 vs. other plants 112, 113
Licensing Process 11, 65
Bounding Principles of Review 14, 281

Metal/Water Reactions 527
Radiolysis 529
Hydrogen in Containment, General
Chronology of Concerns (See also Chronology,
Emergency Response (NRC)) 1129-1152
Control in Containment 461
Hazards 569
Combustion and Hypothetical Vessel Failure 541
Explosion 534-535
Pressure Spike 500-501, 902-911
Removal 533
Hydrogen Recombiners 102, 461

Design Basis Accidents, General 18, 70, 135
I dentification of Important Issues 20, 24, 85,
102, 147, 159, 173, 175
NRC Organization (1969-1979) 274
NRC Organization, statutory origins 2, 261
NRR/IE Division of Responsibilities 19, 269
Overall Performance 23, 104, 105
Safety and Non-Safety Systems, General 18, 152,
175,189
Safety, NRC Basis 8, 70
Single Failure Criterion, General 18
Standard Review Plan, General 19, 281
Standards and Regulatory Objectives 14
TMI-2 65

I ndustry Advisory Group 878, 882
I ndustry Support 845, 876-893
NRC Concern and Interaction 881, 884
Organization and Utilization 154
1269

Make-up Tank Venting 332, 334-335, 337
Man-Machine Interface, General 573-582, 586-596

Operating License for TMI-2
ACRS Letter 283

Metropolitan Edison Company (Also see Operators,
Training)
Briefing of Lt. Governor 834-836
Emergency Staff Organization 811, 827
Management Organization 814, 914
Management Response to Accident 824, 833
News Media Interaction 1057-1070
Operating Experience 916
Quality Assurance Program 919
Radiological Emergency Response 857
Review Committees 917
Emergency Planning 851
Michelson Report, Precursor 144
Mississauga (Ontario) Evacuation 1023-1024
Monitoring Equipment, Radiological 424-429, 867, 870
Fixed 424-427
Mobile 426-427
Personnel Monitors 430-432
Maintenance of 430-431
Performance of 432
Training in Use of 431
Portable 427-429

Amendments, exemptions, and modifications 30
General 30
I ssuance of 30
Review 30, 81-104
Operators (See also Training, Operators)
Licensing 597-599
NRR/IE Responsibilities 272
Manning 604, 827

Operator Error 130, 157, 167, 186, 558-563,
573-580, 822-823, 830
Qualification 598, 604, 849
Requalification 600
Selection 597
Training 599-604

Pebble Springs ACRS Question, Precursor 161
Plans, Emergency
Mississauga, Ontario 1024
NRC 922
Background 933, 1077-1086
Commission Role 933, 1087
Headquarters 940, 1070, 1086-1089
Region 1941, 1070, 1073, 1088-1089
Emergency Response Plans 938, 1077-1091
State, Local 1005-1006, 1018-1019
TMI-2 Licensing 84, 99, 922
Utility

Spectrometry 429
Thermoluminescent Dosimeters 430-432
Whole Body Counters 432

Natural Circulation 144-146, 164-171, 458, 826
News MediaAP Hydrogen Bubble Story 1067
I nterface with Met Ed 841, 1057-1070
Met Ed Decision to Discontinue Press Conferences
1066
Multiple Sources of Information 1070.1073
NRC Credibility 1069-1070
Press Briefings 1057-1070
UPI Meltdown Story 1065
White House Involvement 1064-1065, 1067
Non-safety (Reactor) Regulatory Responsibilities of the
NRC, General 22
Notifications, Emergency (See Communications,
Emergency Planning)

Radiological Emergency Monitoring Plan 368-369,
851,922
Plant Status on March 28, 1979, TMI-2 111, 309
PORV, Design, Operation (See Design) 452, 454,
818,827
Block Valve 150
Post-Construction Permit Review, TMI-2 77
Potassium Iodide ( See Protective Actions-Thyroid
Blocking)
Pressurizer
Design, General 183-199, 449
History of Problems 190-197
Level Indication 139-140, 144-149, 150, 152, 155,
164-171, 175, 183, 199, 456
Surge Line Loop Seals 144, 172-173, 456
TMI-2 Licensing Review 103
Procedures
B&W Review, General 130, 163, 166
Emergency 87, 150, 164
I &E Review, General 118, 130, 166

NRR, Division of Responsibilities with IE 269-272, 935

Observation Center 834
Operating Experience 19

Systematic Evaluation of Operating Reactors 19,
135, 137, 152, 154
TMI-1 108
TMI-2 109

Protective Actions ( See also Evacuation)
Background 1009
Food Interdiction 1031-1032

1270

Protective Actions (Continued)

Radwaste System 344-350
Gaseous 344-347
Augmentation 360-364
Design 344-347

Guides 1010, 1027-1031
Sheltering 1012-1013
Thyroid Blocking 1027-1031
Water Supplies 1032-1033

Liquid 347-350
Design 347-356
Reactimeter 484, 488
Rancho Seco Incident, Precursor 173
Reactor Building 569
Base Mat Penetration 543
I solation 149-150, 461
Sump 465
Reactor Coolant System
Core Barrel Vent 464
Depressurization Discussion 329, 521, 832
Leakage 460
Make-up Flow 186, 503, 842
Non-condensible gases 458
Pressure Control 103, 455
Pump Control 457
Pump Status During Accident on Color Plate III
510, 523, 821
Remote Vent 460
Repressurization Discussion 328, 331, 520-521,
831,839
Reactor Vessel Level 98, 162
Reactor Safety Study, Precursor 142
Recommendations (See Findings & Recommendations)
Recovery Effort 364-365, 845-849
Regulations, General 2, 23
Regulatory Requirements, Non-Licensees 5, 136, 141,
146, 159

Qualification of Equipment, General 472
Quality Assurance
General 44-50, 152
NRR/IE Responsibilities 270
TMI-2 Program 49
TMI-2 Licensing Review 102

Radiation Protection Program, Met Ed 408-445, 922
Audits 432-436
Consideration and Review 408-445
Deficiencies 409-432
I nstrumentation 424-429

Management & Organization 411-420
NRC-Review and Inspection 435-445, 922, 928
Practice 928
Procedures 420
TMI Licensing Review 86, 94, 408-445, 922
Radiological Impacts
Off-site, TM 1-2 Licensing Review 86
On-site, TMI-2 Licensing Review 94
Radiological Monitoring, Offsite 368-397, 867,
1034-1038
Communication Coordination 871
Equipment 368-397, 870
Federal Agencies 371-383, 715-720
NRC 371
Results 383-397
State and Local Government 371, 836
Utility 368-371, 711-714, 859
Radiological Monitoring, Onsite 424-432, 867, 895
Equipment 424-432
Helicopter 383-390
Results 383-390
Utility 383-389, 859
Radiological Monitoring 827-870
Primary Coolant 1044
Radiological Releases 355-364,842
Quantities 355-364
Radionuclide Distribution 355-364
SourceSteam Venting 834
3000 mr/hr release 352-355
1200 mr/hr release 1064
Times 725-735

Regulatory Requirements Review Committee 17, 38-44,
80,82

Release Mechanism and Pathways, Radiological 350-355
Gaseous 352-355
Liquid 350-351

Safety Issues (See also Licensing Process, Issues andGeneric Issues)
I dentification 2, 11, 17, 169
NRR/IE Responsibilities 17, 269
Shared Activities, TMI-1 and TMI-2 115
Sheltering Advisory 1012-1013
Sirens, Evacuation (See Evacuation, Sirens)
Site Emergency, Declaration of 828
SitingGeneral 9
TMI-2 Licensing 86
Socioeconomic Impacts
Economic Effects 633-640
I nformation Flow 620-622

1271

Training

Socioeconomic Impacts (Continued)
I nstitutional Effects 640-643

NRC Requirements 598
Operator 140, 144, 151, 155, 159, 162-164, 186, 824
Evaluation 601-604
Simulator 140, 163, 602
Radiological (RC/T's) 421-424
NRC Requirements 421-423
Program Deficiency 423-424

Longer Term Effects 644
Public Response 622-633
Source Term, Radiological 355-360
Gaseous (noble) 358-360
Quantity 360
Radionuclide Distribution 360
Source 352-355
Liquid 350-351
Source 350-351
Radioiodine 355-358
Quantity 358
Time 356-357

Utilities' Responsibilities, General 5, 851

State Response, Agency-by-Agency Account 1191-1203
Steam Discharge (See Radiological Releases) 834
Steam Generators 165-171, 189, 449, 458, 835
Sternberg Memo, Precursor 175
Systems Interaction, General 19

Technical Plant Support, Federal Agency 1044-1045
Technical Qualifications, Met Ed 55, 101
Technical Specifications
NRR/IE responsibilities 269
TMI-2 Licensing 101
Temperatures
Hot Leg Color Plate III, 894
I ncore Thermocouples 504-505, 825, 898

1272

Ventilation Systems 344-347, 360-364

Water Discharge (See Radiological Releases)
White House Involvement
Communications 1041
Federal Coordination 997, 1004
I ndustry Support Activation 885
President Carter's Visit 999, 1042, 1068
Public Information 1064-1065, 1067
Whole Body Counting, Radiological 431-432
Offsite 400
Onsite 431-432

NUREG/CR-1250, Vol. II, Part 3