Ethics Case Study: Three Mile Island Accident by Max Rego

Max Rego On March 28, 1979, the TMI-2 reactor at the Three Mile Island nuclear power facility underwent technical issues that caused several portions of the system to malfunction. The reactor eventually partially melted down due to improper human intervention. This paper will outline the events that led up to and followed the incident, and will include information on the results of the investigation performed by the Nuclear Regulatory Commission (NRC), as well as the policy changes made by the NRC to prevent future accidents. Also included will be the implications of the ethical guidelines forgone in the design of specific portions of TMI-2 and by those who worked at the Three Mile Island facility. Prior to the beginning of the accident, which occurred at 4:00 A.M., three separate problems had been encountered at the TMI-2 facility which led to the start of the accident. First, a coolant leak, known to the operators, had been occurring the previous day and in the early hours of the morning. The leak was normal, as several relief and safety valves were implemented to allow some coolant to leak to release large amounts of pressure from the coolant system. Without these valves, the coolant system could rupture. According to the NRC, the amount of coolant leaking was within regulation; however, the leak actually exceeded the standardized limit. This leak, although not serious enough to cause issue, did cause for erroneous temperatures to be indicated within the coolant drain piping. These temperature indications became to be ignored by the operators, eventually masking a more serious leak that would occur several hours later. The second problem was unknown to the operators prior to the accident and is perhaps the most serious of the three. Two valves were closed within the auxiliary feedwater system that were supposed to be open under normal operating procedures. Main feedwater could not make it to the condensate pumps during this time, so the auxiliary feedwater was supposed to replace it. The closure of the valves prevented this action from occurring. This problem, like the first,

Max Rego would have been fine had it occurred on its own, but in combination with problem three, the accident was initiated. The third problem had started 11 hours before 4:00 A.M. The specifics of this problem could be detailed in a lengthy, entirely separate report. To keep things concise, a resin buildup occurred which forced water that was otherwise trying to exit back into the condensate pumps. This caused the condensate pump to trip, and so in cohorts with problem number two, the accident began [1]. Before getting into the details of the accident itself, it is important to note that the three problems detailed above were not the beginning of issues experienced at Three Mile Island. Victor P. Orlandi of the Metropolitan Edison Company (the owners of Three Mile Island nuclear facility), wrote a paper two years prior to the accident that details some of the operating issues that he experienced while working at TMI. Some issues are irrelevant here; however, other issues relate to problems experienced before the major accident. As shown above, not one of the three problems could have tripped the accident individually, but they all freakily happened within the same time frame, leading to a disaster. One such issue documented by Orlandi is the effect of a faulty relay. Ultimately, a single relay failure caused an entire reactor to trip due to a false high pressure reading. [2] This issue could have led to an accident had it occurred in the same time frame as another issue. The systems at Three Mile Island were not well designed, simply put. Immediately following the trip of the condensate pump, as described in problem three, coolant pressure began to increase due to the resin buildup and the position of the valves on the auxiliary feedwater system [1]. To release this pressure, a relief valve automatically opened. After the pressure was released and back to normal levels, the relief valve was supposed to close; however, it remained open, causing coolant to continuously leak from the valve. At this time, as described above, the operators thought the coolant system was behaving normally due to the

Max Rego erroneous readings they were already receiving from the minor coolant leak. The operators thought that the pressure was still increasing in the coolant system, so in an attempt to lower the pressure, they lowered the reactors amount of emergency coolant water. In addition, the operators turned off the reactor coolant pumps to inhibit high levels of vibrations. By doing these things, the operators prevented the reactor core from being cooled, which caused a sharp, dangerous increase in temperature. The high temperatures in the reactor core caused the nuclear fuel rods to explode. The now exposed fuel began to melt, causing the partial meltdown of the TMI-2 reactor core. It is important to note that despite the partial meltdown, the building that held TMI-2 did not collapse. This prevented radioactive material from being released to the environment and is the reason why no health effects have been reported from this accident [3]. Many investigations soon followed the accident, but the two official investigations were those completed by the NRC and the Presidents Commission. The Presidents Commission was a group of twelve people created by the President of the United States to investigate the TMI accident. Their investigation held more purpose than just to find the cause of the accident. The overall task was to look into the issues surrounding the nuclear power industry at the time and to make a recommendation on how to continue operation of the industry within the United States. The Presidents Commission eventually came to this conclusion: 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 [4]. It was this statement along with the conclusion to the NRCs investigation that new policies were created to prevent accidents from happening in the future. At least 12 new policies were adopted

Max Rego by the NRC. The summaries of these policies are quite lengthy, but some key changes worth mentioning are: (1) building and equipment standards were raised, (2) requirement of at least two NRC inspectors live near every plant in the country to inspect every day, and (3) the creation of the Institute of Nuclear Power Operations as a policy enforcement agency [3]. Due to these policy upgrades and the overall rise of industry standards, the United States has yet to see a nuclear power accident more serious than TMI. All lapses in engineering ethics occurred prior and during the accident and are related to the design of the system used at the Three Mile Island facility, the actions taken by the facility operators in the events leading up to and during the accident, and the policies of the NRC at the time of the accident. Although the operators made poor decisions (as described above) while the accident was taking place and ultimately made the situation worse, it is important to realize that their actions were completely warranted as they tried to fix the issue at hand. As mentioned, the system at Three Mile Island had major design flaws. While it is normal for certain parts of equipment to fail after the designed life time has expired, this wasnt the problem with the TMI system. The problem was the fail safe system, or lack thereof. As seen from Orlandis paper, he experienced an entire reactor trip due to the failure of a single relay [2]. The major accident at Three Mile Island occurred because three different and small problems, similar in magnitude to the faulty relay, happened together. With the auxiliary feedwater valves in the closed position, the tripped condensate pump couldnt push any water out. There should have been an implemented fail safe system that would prevent the condensate pump form tripping altogether while the auxiliary feedwater valves were in the closed position. The failure of the design engineers to properly design a fully working system could have been due to negligence or something else entirely; no matter, this directly violates the National

Max Rego Society of Professional Engineers Fundamental Canon and Rule of Practice #1: Engineers shall hold paramount the safety, health, and welfare of the public [5]. Improperly designing a nuclear power system can certainly do damage to the public. Fundamental Canon and Rule of Practice #1 is again violated, this time by the operating engineers running the facility. The operators ignored vital temperature instrumentation on the TMI-2 coolant system due to the erroneous data that was displayed earlier that day. Had the operators looked at the instrumentation and realized that a major coolant leak had started to occur, they could have possibly prevented the accident from occurring. The operators negligence put fellow co-workers and the public in danger. The NRC was also found to have violated the engineering Rules of Practice. A study of the NRC was conducted by the United States General Accounting Office which concluded that the NRCs performance can be characterized as slow, indecisive, cautious--in a word, complacent.[resulting] from a lack of aggressive leadership as evidenced by the Commissioners' failures to establish regulatory goals, control policymaking, and most importantly, clearly define their roles in nuclear regulation. The results of the study clearly show that the NRCs attitude towards policy making was not up to par with the serious dangers of the Nuclear Power Industry [6]. This again violates Rule of Practice #1, as the NRC did not put the safety of the public first. It could even be considered that Rule of Practice #5: Engineers shall avoid deceptive acts, was violated. The NRC had a job to protect the public by regulating the Nuclear Power Industry. The public was somewhat deceived by this false protection that the NRC had guaranteed. The ethical Rules of Practice were violated by the engineers who designed the TMI-2 system, the operating engineers in charge of safely running the TMI facility, and the engineers at

Max Rego the NRC. In combination with three minor problems occurring freakily at the same time, these ethical violations resulted in an accident that could have caused health effects among the general population of the United States. Luckily, no health effects from this accident have been recorded [3]. Although this accident was a tragedy, it was sadly, a necessary step to improve the policies, industry standards, and overall safety of the United States Nuclear Power Industry.

Max Rego References [1] J. F. Mason, The technical blow-by-blow: Details of the Three Mile Island accident as excerpted and edited from interviews with Nuclear Regulatory Commission investigators, Spectrum, IEEE, vol. 16, no. 11, pp. 33-58, Nov., 1979. V. P. Orlandi, Operating Experience with Control, Instrumentation and Electrical Systems at Three Mile Island Nuclear Station, Metropolitan Edison Co., Reading, PA, Nuclear Science, IEEE Transactions on, vol. 24, no. 1, pp. 714-716, Feb., 1977. U.S.NRC. (2013, February 11). Backgrounder on the Three Mile Island Accident [Online]. Available: http://www.nrc.gov/reading-rm/doc-collections/fact-sheets/3mileisle.html R. W. Peterson, Three Mile Island Lessons for America, Presidents Commission on the Accident at Three Mile Island (Member), Aerospace and Electronic Systems, IEEE Transactions on, vol. AES-17, no. 2, pp. 229-233, March, 1981. M. W. Martin and R. Schinzinger, Appendix B: Sample Codes of Ethics and Guidelines, in Ethics in Engineering, 4th ed. New York, NY, 2005, Appendix B, pp. 300-302. S. L. Del Sesto, Social and political perspectives on nuclear regulation after three mile Island, Technology and Society, vol. 9, no. 2, p. 1, Jun., 1981.

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