TMI Report:People problems vs. Equipment

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Popular discussions of nuclear power plants tend to concentrate on
questions of equipment safety. Equipment can and should be improved to add
further safety to nuclear power plants, and some of our recommendations
deal with this subject. But as the evidence accumulated, it became clear
that the fundamental problems are people-related problems and not
equipment problems.

When we say that the basic problems are people-related, we do not mean to
limit this term to shortcomings of individual human beings -- although
those do exist. We mean more generally that our investigation has revealed
problems with the "system" that manufactures, operates, and regulates
nuclear power plants. There are structural problems in the various
organizations, there are deficiencies in various processes, and there is a
lack of communication among key individuals and groups.

We are convinced that if the only problems were equipment problems, this
Presidential Commission would never have been created. The equipment was
sufficiently good that, except for human failures, the major accident at
Three Mile Island would have been a minor incident. But, wherever we
looked, we found problems with the human beings who operate the plant,
with the management that runs the key organization, and with the agency
that is charged with assuring the safety of nuclear power plants.

In the testimony we received, one word occurred over and over again. That
word is "mindset." . . .