In June 1995, an inspector poking around a nuclear plant in Ontario became alarmed. He found computer games on three of the control room's four computers. And reactors were running despite a buildup of explosive deuterium gas.
A few days later, the inspector found excess humidity in the huge Pickering B plant, which is part of Hydro Ontario's nuclear complex on Lake Ontario, the largest nuclear site in the world. The humidity had the potential to allow an electrical "flash over" that could ignite a fire. "I began to put the story together in my head," he says, requesting anonymity.
But even worse, after his inspection team reported the safety dangers, he was unconvinced that changes would actually occur.
His tale of management lapses - or what is now called a "special nuclear cult" - was writ large on Wednesday. Ontario Hydro, the largest electric utility in North America in capacity, released a report citing a "lack of authoritative and accountable" leadership.
The result: 7 of 19 operating nuclear reactors will be shut, with a big shift to coal and oil plants.
The catalyst for the shutdown of Canada's nuclear flagship was a new, scathing, independent report that rates all of Ontario's nuclear plants as "minimally acceptable," a rating that would probably put them on the Nuclear Regulatory Commission's "watch list" if they were in the United States, the report said.
On Tuesday, Allan Kupcis, the president of Ontario Hydro, resigned, even though it was Dr. Kupcis who had asked for a "brutally honest" report by the seven nuclear experts from the US.
The report blames a culture in Ontario Hydro's nuclear division that tolerated cost overruns and slipshod operation.
The public was never in any danger, the report says. But while still minimally safe, the remaining 12 Ontario Hydro nuclear reactors need drastic changes to keep them safe to operate. It will not be a cheap solution.
The nuclear division was chronically short-staffed and desperately needed retraining at the same time, company officials say.
G. Carl Andognini, the company's chief nuclear officer - a US expert hired last year to clean up Hydro's nuclear mess - says the seven reactors had to be shuttered in order to retrain the thousands of workers who must be taken out of production.
THE estimated cost of upgrading the remaining nuclear plants, bolstering management, upgrading training, and buying replacement power will be C$5 billion to C$8 billion (US$3.7 billion to $5.8 billion) over five years, the company says.
Canada's 21 nuclear reactors supply 17 percent of the nation's power needs. Nuclear energy supplies about 22 percent of US power needs. Ontario's reactor fleet has allowed it to export power to Michigan and Canadian provinces. Now the company must fire up old fossil-fuel plants, buy coal to run them, and purchase power from the US and elsewhere.
The environmental group Greenpeace lauded the company for shutting the "dangerous" nuclear reactors, but criticized it for filling the gap by using three fossil-fuel plants. Greenpeace says emissions from such plants will grow by 300 to 400 percent. The company says it will remain within government-set standards.
"This is the beginning of the end of nuclear power in Canada," says David Martin, research director at the Nuclear Awareness Project in Uxbridge, Ontario. "It's the largest nuclear shutdown in history of nuclear power. No utility in the world has ever shut down seven reactors at one time."
Shock waves from the report are rippling through the nuclear-power industry in Canada. (Other countries may rethink buying nuclear reactors from Canada, observers say.)
How could a crisis of this magnitude grow undetected for more than a decade and finally hammer Canada's top nuclear utility?
"Our problems are people, not machines," Ontario Hydro chairman William Farlinger said at a news conference Wednesday. Deterioration at the nuclear division had gone on for 10 years, accelerating in the last few. Managers did not notice the problems until the last few years simply because they believed what the nuclear engineers they had hired told them - that everything was going smoothly, he said.
"The nuclear unit [of Ontario Hydro] was operated over all those early years as some sort of special nuclear cult," he told reporters. "I'm told this has not been unusual elsewhere in the world, and senior management didn't dig into what was going on in this special unit to the extent that we might now say they should have."
The report by Mr. Andognini's team of six other US experts says the company failed to make the transition from building reactors to managing them. The company left in charge of day-to-day operations the same nuclear engineers who built the reactors. But they were less capable as managers.
The report described a mind-set based on the reputation of CANDU reactors as the safest, most cost-effective, and reliable nuclear reactor design in the world.
A key problem, according to the report, was that the company's managers held the attitude that "our technology is so different and superior that we really haven't anything to learn from stations who use other technology." This "exhibits the kind of technical and managerial attitude that has contributed to the current state of station performance," it says.
Gordon Edwards agrees that a "cult-like" mind-set may be a fair description of Ontario Hydro's nuclear management. As president of the Canadian Coalition for Nuclear Responsibility, based in Montreal, he has watched the growth of the Canadian nuclear industry since 1970.
"It's like a sacred mystery that people outside the nuclear club are not equipped or entitled to understand fully," he says. "It's not unique to Canada. But this report shows a tremendous amount of sloppiness and lack of accountability at Ontario Hydro. You might say the cultish feelings of this inner sanctum replaced ... prudence."
Unlike US pressurized light-water reactors, Canada's heavy-water designs can use low-grade uranium and can be refueled while the reactor is still working, leading to a reputation for "robust" design.
Andognini told reporters CANDU technology was not to blame but rather management failures. But several of the reactors being shut down, such as those at the Bruce A facility, are barely 20 years old - only half their design life of 40 years.
While the company hopes to one day restart the reactors, many observers say this is unlikely because costly nuclear power is simply uncompetitive with other technologies such as gas-fired turbines.
Ontario Hydro finds itself late in moving to rid itself of the cost of generating nuclear power, trailing some US utilities. The company is widely expected to lose its monopoly on electricity sales in Ontario in the next few years and is struggling to pay off debt.
That will be delayed now. And the critical report may accelerate moves to deregulate its home market.