this shows a strange (to me) set of paradigms. I don't understand
how TMI is characterized as a member of your first class (not
following) vice the second class (inadequate). I further don't
understand the second class at all (it seems to assume a model in
which regulation is a primary defense for ensuring safe behavior).
Given the implied philosophy, I then can't see why the Herald is let
off from the presumed burden that regulation should have saved us.
They devalued safety, they had demonstrably inadequate safety
barriers (door indication, inadequate ballast pumps, they discouraged
operating experience sharing, etc.)
It's not that I don't see a role for regulation. I do very much. We
could not have accomplished as much as we have without the
regulations and the regulatory point of view. While I may not think
they are vital, some degree of regulation is necessary because as the
number of power plants grows the belief that "all plants will do
what's right simply because it's right" is increasingly quixotic.
It's just that any model that allows the absence, the inadequacy, or
the failure to follow regulations to be a major contributor to the
causal model apparently offends my views of accountability.
Regulation should never be the primary causal agent for safe
operation. An organization that so views regulation as a primary
driver of safety seems already doomed.
I actually like your third category. Regulations that compel or
encourage irrational behavior or pull resources off important
behaviors can be serious threats. These can provoke a "do what's
right or do what's legal" reaction that is never healthy. I'd
suggest the NRC's intended rule making on fatigue is a minor but
clear example of this class. It seeks to pull supervisory resources
off performance management to manage instead an issue that hasn't had
an impact on plant safety or risk.
Finally, your principle for transparent compliance seems to two
obvious problems. First, the ability of the auditor to tell what's
going on is a value to the auditor, but it is not the key point.
Admiral Rickover used to lecture that the first obligation was to do
what's right (in this case comply with regulation). If you can do
that and give the auditor's what they need, that's even better, but
in my mind, that's a second goal, not a primary goal. The second
problem is the dangers of candor. Transparency is a good thing when
used as a tool for improvement, but consider two plants: one is
brutally honest in their assessments of an event and one is tactfully
accurate. Which plant is rewarded by the regulator and the public?
We're seeing this in the howling about worldcom. Nixon saw it after
Watergate. In his Frost interviews, when asked what he'd do
different, he said, "next time i'd destroy the tapes". That is a
recognition that too often investigations become vehicles for
punishing the guilty versus vehicles for preventing the next event.
The degree to which candor is realistic depends on which vehicle is
> Date: Tue, 2 Jul 2002 07:35:20 -0400
> From: "Dr. Bill Corcoran at NSRC" <firebird.one@...>
>Subject: Re: [rootcauseconference] Re: Regulation
>Some RCA's are done because of the consequences of not following
>Some are done because regulations are inadequate. (Brown's Ferry Fire,
>ValuJet, Bhopal, Chernobyl<?>)
>Still others are done because regulations encouraged dysfunctional behaviors
>and conditions. (Davis-Besse, partially.)
>Some few involve no regulatory implications. (Herald of Free Enterprise<?>)