. . . It was one year ago today [April 11] . . . that my wife and I walked into the Oval Office in the White House. I had never met the President of the United States before; and if anyone had suggested 48 hours earlier that I would be walking into the Oval Office to accept the chairmanship of a presidential commission, I would have told that person that he was totally out of his mind. But somehow there we were; and that led to six of the most difficult but also most fascinating months of my life. . . .
Let me summarize some of our findings for you. When we started, four weeks after the accident, everybody was saying that it was very simple case of operator error. It was the failure to recognize that a certain valved had stuck open and to recognize certain other symptoms thad led the operators to turn down the emergency cooling system, and indeed there is no question that that action converted what should have been a minor accident that you would never have heard of into a truly major accident. I remember vividly at one of our earliest open hearings having these operators as witnesses that they would testify under oath that they had never been trained for anything of the kind that confronted them; and I remember that I did not believe them. Before we finished, we would prove that every word said was true. They had indeed not been prepared. . . .
For example, we discovered that it was entirely legal under Nuclear Regulatory Commission requirements -- and it became standard practice -- that the operators were only required to be trained for an accident where only one thing went wrong. They were never given any exercise where two things independently might to wrong. And since in this particular accident threem things independently went wrong, they told us the complete truth when they said that they had not been trained for anything of the sort. One of the three things turned out in our analysis not to be important; but the combination of two of them created a set of circumstances for which they had not been trained. . .
A second major area that became a personal concern of mine because of my background was the information available to operators in the control room. I shall never forget a visit to the plant at Three Mile Island where we toured all over the sister plant. . . . First of all, you have to picture a wall . . . entirely filled with little panels that serve as warnings. I think there are close to a thousand of them if my memory is right. There was a canned lecture being given to our commission all about the control room which I was not interested in, so I watched what went on.
After about five minutes I hear some sort of bell going off and an operator does something. The lecturer didn't even stop, so I stopped him and asked him if he would mind telling us what happened. He said that an alarm went off -- and we would later learn tht an alarm does not necessarily mean something you have to be alarmed about, it simply means that it is something the operator should look at and possibly do something about -- and he pointed out that behind each of those little plastic sheets there was blinking light that told the operator what the problem was, and he pushed the right button and the alarm stopped and that took care of it.
So ten minutes later when another alarm went off. . . I spotted the blinking light. The operator went and looked at it and did the right things and it went off. Fifteen minutes later I hear the alarm sound again and I look all around and there is no blinking light. I see the operator scurrying all over the place and he calls one of his assistants over who starts removing these little plastic parts one by one. I raised my hand again and said, "Sir, would you mind asking the operator what is going on now?" They had a whispered conversation and said, "Oh, it's nothing important. It's just that as you may have heard an alarm went off but no light is blinking which means that the appropriate light bulb is burned out."
And then I watched for the next ten minutes while they removed those little plastic sheets one by one and they did indeed find the light bulb that was burned out (it was just line an ordinary flashlight bulb), they replaced it, and it started blinking and then they knew what was wrong.
And I'm afraig I got myself into very serious trouble afterward because I did within hearing of the media make a remak that I did not think that this particular control room represented the greatest glory of modern technology, and I said that it was at least twenty years out of date. I got greatly criticizer for that and I think rightly so because my statement turned out to be false. Later we found within the documents of the Nuclear Regulatory Commission a document written ten years earlier in which an expert had said that these control rooms were thenm twenty years out of date.
Now, I want to tell you something fascinating. In spite of this, we started out, you know, with the conviction that the big problem was equipment. Before we were through, our overwhelming conclusion was that, although the control room was terribly badly designed from the point of view of the people who had use it, we found that the basic equipment was amazingly good. As a matter of fact, it provided a surprising degree of safety in spite of the incredible abuse that the equipment took on that particular day. And we would later conclude that not all the safety features had been used up. There was one more line of defense left, in spite of horrible misuse of it. It was slowly that the commission's attention changed completely from equipment to people. And our ultimate conclusion was that this was one of the most horrendous "people problems" we had ever run into.
We found it at three different levels. I have already told you about the training of operators. We found similar problems in the attitudes of management , and of course we found it within the Nuclear Regulatory Commission.
It is an industry that seems to be hypnotized by equipment (and, as I said, it makes darn good equipment) but they have a fundamental belief that you can make equipment totally foolproof. Three Mile Island was conclusive proof that you can never make any equipment totally foolproof.
One of the disturbing things that we would learn is that there was such a conviction that nothing really bad could happen, that clear signals of problems were ignored. The clearest signal was an incident that we would investigate in considerable depth that happened at a plant called Davis-Besse in September 1977 . It had very strong similaraties to what would happen at Three Mile Island a year and a half later.
Again, two minor malfunctions, a valve sticking open and the operators turning off the emergency cooling system. Our big find was a document within the records of the manufacturer of the equipment by an engineer called Dunn who was in charge of their emergency cooling system in which he states that he was very disturbed about what happened in Davis-Besse. The document says roughly that they were extremely lucky that this happened at a plant which was operating under low power and had been recently refueled and therefore there wasn't a great deal of residual radiation. Dunn says in so many words that, if this had happened under different circumstances, they would have had extremely serious core damage. And it goes on and states absolutely correctly that they must send the operators clear instructions; and he comes up with instructions that all of us would agree would have prevented Three Mile Island. Because of a bureaucratic nightmare within that organization, that document gets kicked around and never gets out.
There's a parallel to that incident in the case of a low- level inspector within the Nuclear Regulatory Commission who also worries about Davis-Besse, and this has a very sad ending. He goes on for months and months trying to communicate his concern and finally takes advantage of something called an open-door policy and goes and sees two of the commissioners who take him very seriously and order an investigation. But March 21 of 1979 was only one week before Three Mile Island. It was too late. . . .
I saved for last the Nuclear Regulatory Commission which was part of our charge and we spent a great deal of time on it. I have to report to you and that that agency, at least the way it was a year ago today, was a total disaster. It was clearly not part of the solution of the problems of nuclear energy. In our judgment, it was a serious part of the problem.
It's not that it was negligent in publishing regulations. It published tons and tons and tons of them. It may be perhaps the most heavily regulated industry anywhere. It is just that, in spite of that, that agency had missed some of the fundamental issues concerning nuclear power.
They would publish incredible volumes of things that you and I would judge in third or fourth order of importance, and yet miss some of the most significant issues. For example, they missed operator training. Their inspection and enforcement was one of the weakest; those on our commission who have industrial experience told us they had never seen one that performed so poorly. They had the lovely habit of taking some very difficult problems and labeling them by a special label called "generic" which allowed them to put them on the shelf where they would sit for long time without being resolved. And, of course, as I told you before, they also had no systematic way. . . of learning from experience.
It is an agency that was so convinced that the equipment was so foolproof that nothing bad could happen that they honestly believed that what they were doing was sufficient to assure nuclear safety. Therefore, it not surprising that, in spite of our diverse backgrounds on the [investigatory] commission, we reached the unanimous conclusion that fundamental changes are necessary, both within the industry and particularly within the [Nuclear] Regulatory Commission, in people and in attitudes . . . And we came up with a long list of recommendations to try to improve the safety of nuclear plants significantly.
At the same time, we also had to conclude that we did not find any problem that was not curable or any problem that could lead us to the conviction that nuclear power is too dangerous and cannot exist as a viable alternative energy source. And therefore, as one person who had no views on nuclear power before I chaired this. . . I now dom have an opinion. The opinion is very simply that if, during the next couple of years, recommendations like those we came up with are implemented, I think nuclear power can, at least for the forseeable future, be one of the alternatives offered to mankind. I am equally convinced that if recommendations like ours are not implemented, if a year from now it is business as usual, then nuclear power is going to put itself out of business by the kind of attitudes that we have found. This was why we recommend a permanent watchdog committee for nuclear power -- which I understand will be set up very shortly -- so that the American people can know that our recommendations are or are not being implemented. . . .
What I really wanted to talk to you about are some concerns that emerged as I watched our own commission struggle for six months of very, very hard work to reach agreement on one small piece of the energy problem. . . . As I look at the federal scence, I have tremendously serious worries as to how our nation will be able to face up to the problems of the immediate future and how we will ever be able to come up with effective solutions to immensely complex problems. . . .
First, any one of them is vastly more complex than Three Mile Island. I mention that because I know how hard it was for twelve honest, extremely hard-working, and bright individuals to try to come to a consensus on that. . . .
Secondly, I keep talking as if the problems would be solved entirely by physical scientists. Of course that's not true. If you're talking of problems on a national scale that will affect people all over the country and the world, you've got to get more input from the social scientists. I have said this for at least twenty years -- that the social scientists are unfortunately still lagging behind the needs of the nation. Of course, there is no mnagic way of getting a breakthrough, but we desperately need some major breakthroughs in the social sciences.
Thirdly, and most disturbingly to me, we would again and again run into cases where emotions influence the judgments of even very distinguished scientists. I was reminded of that famous historic incident when Galileo was forced to recent some of his great discoveries because they ran against religious beliefs of the tim. Today the problem is not with religion, but I was reminded of that incident because I ran into scientists whose beliefs, let's say, on nuclear power or on other subjects are practically like fanatic religious beliefs. And I hasten to say that I ran into this at both extremes of the nuclear debate.
These people distort scientific judgment and state things with certainty that they could at most give a very small probability to. And they will put their scientific reputation on the line, and say things that deep down I think they must believe are not so. They become advocates instead of unbiased advisers. I'ts incompatible with the fundamental nature of science and, very dangerously, it creates an atmosphere in which there is a distrust of experts because today, even on subjecs where the hard evidence i overwhelming, you can always get an expert if the issue is sufficiently emotional, who will dispute it, and therefore throw all science into disrepute. . . .
But let's suppose we get past that and we do [achieve] a national consensus. Someone has got to pick a plan for energy, for transportation, for health care, for inflation, whatever the issue may be. . . .
At the moment, I do not see the machinery. I guess my views on the executive may be somewhat influenced by the Nuclear Regulatory Commission about which I made some remarks earlier. I am sure this agency is not typical -- at least I hope it is not typical -- of federal agencies. But even if it isn't, over a period of decades the executive branch has grown enormously. It is gigantic. It is splintered. And it is full of jealousies amongst agencies at a time when one desperately needs interdisciplinary teams -- people with various kinds of background cooperating. . . .
But I am much more worried about Congress. I am willing to concede that Congress has an impossible job. At least I believe that the way Congress conceives of its job is impossible. . . . Again, we went to Congress. We received a most sympathetic hearing from them. But generally they were poorly briefed; and there was not time for any in-depth discussion during those hearings.
I do realize, of course, that, for each congressman there, the issue that was overwhelming in our minds at that moment was but one of a hundred issues that that congressman had to deal with. Congressmen probably have a quite small staff, which is typically young and may be inexperienced. They certainly cannot be experts on all hundred of those issues. And on top of that, in the case of the House Representatives, all of them are continually running for re-election, which consumes an enormous part of their energy.But even granted all of that, I had the impression that Congress has particular difficulty coming to grips with those issues that involve significant input from science and technology.
They cannot possibly be experts, not the way they are elected. But they even seem to be confused on the use of experts. At least that is the impression that I was left with. I can think of distinguished physicists on the [investigatory] commission being asked a question that was not a question in physics at all but a pure value judgment. I thought that we elected congreesmen to make value judgments on behalf of the nation. At the same time, several congressmen very freely expressed strong statements on scientific facts. I though that is what we have scientists for. . . .
My conclusion is this: I've heard many tine that, although democracy is an imperfect system, we somehow always muddle through. The message I want to give you after long and very hard thought it that I'm very much afraid that it is no longer possible to muddle through because the issues we have deal with do not lend themselves to that kind of treatment. Thereforee, I conclude that our democracy must grow up. . . .
First of all, what's lacking to me on the federal scene is the existence of respected, nopartisan interdisciplinary teams who could at least tell us what is possible -- and what the pluses and minuses are -- on various different solutions for energy or inflation or any of the other problems.
Let me take energy. What I would love to see established with National Academies, or whatever mechanisms will give it respectability, is a team that will struggle the way our commission did and say: "OK, there are lots of suggestions around, and most of them don't work. But here are six different plans, any one of which at least is possible. Now let us tell you for each one of them what it costs, what's good about it, what's bad about it, ho dangerous it is, what the uncertainties are in it."
At least each one would be a well-integrated and well-thought-out plan that in itself makes sense. Then I would trust democracy to choose among those. I think that if the President and Congress had these and could choose, I would trust democracy. I do not trust democracy to try to put together such a plan by having each committee of Congress pick one piece of it. . . .
Secondly, and not unnaturally, I want to put in a plug for the role of universities . . . [they] generally used to play a much more major role in long-term research and in worrying about the problems of the nation. Of course, there's been a huge cutback in spending on pure research, which came about under the Nixon administration. We have never recovered from that, and I think it is vital that this should be restored because some of the brain power that is desperately needed for this effort is spread out amongst the universities and we are losing a vital resource.
But there's a second role of universities. . . . Seeing the difficulty today's leadership has in grappling with these problems, we must think very, very hard as to how to educate the next generation of leaders so that they can, as individuals, not at second hand, understand and come to grips with the monumental issus of the nation.
Thirdly the media -- just some suggestions. I'd like to suggest that at least the national media . . . should hire some people who know something about science and technology. I would like to go one step beyond that and make a more radical suggestion, that once they hire them they allow them to speak for themselves and not through the mouths of others. There seems to be a general belief, particularly on television, but also in some of the written media, that you have to have, in effect, professional actors after you have been interviewed who will say what you have said so the people can understand it, or in writing that you must have professional writers write it because certainly scientists and engineers can't write in such a way that people will understand it.
Now look, I'm not saying that all scientists are all engineers could go out there and talk so that most people know what they are talking about. But you and I both know significant numbers of them who can, and can do at least as good a job as those who are now doing it. At least there wouldn't be major mistakes made in translating it by having it go through several filters before it reaches the American public. Of course, I do hope that somehow TV and the newspapers find the means to devote time and space to the serious issus.
The fourth point I will say nothing original on; but I've joined a group (psychologically) that has been advocating reform in the electoral process, particularly in the terms of office of our elected representatives. . . . If one could, for example, change the House term to four years, representatives wouldn't be continually running for office. I suspect that something like a six-year nonrenewable term for the president of the United States might be very good. . . .
I come to my last point. It is the most important one, and it is difficult to verbalize. I think what is most important for our nation is to recognize that the present system does not work. It has to be recognized that it was designed for much earlier age, for a simpler age.
Even 200 years ago, the founding fathers made choices. They opted for democracy; but they did not opt for Athenean democracy. Two hundred years ago it would have been totally impractical to call all citizens together into the market place and them vote on every issue as it occured. And yet today we have essentially the same system that we had 200 years ago without any reconsideration of how much more complex the world has become. And I think it is time to rethink the issue, because I believe that Jeffersonian democracy cannot work in the year 1980.
I'm not advocating the abolition of democracy. What I am advocating is saving democracy. But what I am saying to you -- and I don't say this lightly, believe me -- is that the only way to save American democracy is to change it quite fundamentally by changing the fundamental decision making process at the federal level so it can come to grips with the enormous and complex issues that face this nation. And that's the message I'd like to give you.