Shouldering Risks

by Perin, Constance

• ISBN13: 9780691127774
• ISBN10: 0691127778
• Format: Paperback
• Copyright: 2006-10-02
• Publisher: Princeton Univ Pr

Summary

At the world's some 440 nuclear power plants, experts continually monitor their wide safety margins, and at signs of trouble seek out the sources and recommend changes. Too often for their comfort, and for ours, a subsequent problem reveals that these changes were ineffective or never made. Why this self-defeating pattern? What in this technology's culture of control might undermine experts' best intentions? What kind of problem is it to reduce operating risks? Following brief highlights of this industry's history over the last twenty years of accidents, near-accidents, and institutional changes,Shouldering Riskspresents excerpts from interviews with some sixty experts about four relatively recent events at three U.S. plants. Drawing also on her earlier field studies at eleven plants in America and abroad, on industry documents, and others' research, Constance Perin identifies unacknowledged elements in this industry's culture of control; for example, control concepts for reactor design, construction, and regulation carry over to risk handling and event analysis, whose efficacy depends instead on recognizing and interpreting the significance of technical and contextual signals on daily display. Far more than the sum of its parts, this highly knowledge-dependent technology operates along an axis of meanings, not only along an axis of functions. A culture of control is, like any culture, an intricate system of claims about how to understand the world and act in it. Here, claims pivot around the dynamics of control theory and productivity based on particular assumptions about the relationships of humans to machines, models to reality, certainty to ambiguity, rationality to experience. These four events and accident analyses show that such assumptions can confound control and produce misleading meanings. Shouldering Risksreimagines a broader and deeper culture of control to reshape our understandings of the intellectual capital appropriate to designing, regulating, organizing, and managing this risky enterprise and, perhaps, other such technologies already here or to come.

Table of Contents

Preface	ix
Acknowledgments	xxi
Reading Notes	xxv
CHAPTER ONE Complexities in Control	1	(34)
The Limits of Regulation and Self-Regulation	5	(4)
The Tradeoff Quandary	9	(8)
Concerns, Commitments, and Control	17	(6)
The Nuclear Connection: Naval and Corporate Orders	23	(5)
The Cycle of Self-Improvement: The Event Review System	28	(7)
CHAPTER TWO Arrow Station: A Leaking Valve in Containment	35	(63)
An Account of a Valve Repair Effort	35	(9)
Event Inquiries	44	(4)
The Teams' Reports	48	(11)
Insights and Excursions	59	(29)
The Parts Template	88	(10)
CHAPTER THREE Bowie Station: A Reactor Trip and a Security Lapse	98	(46)
An Account of an Automatic Reactor/Turbine Trip	98	(2)
Trip Event Review Team Report	100	(3)
Insights and Excursions	103	(17)
An Account of a Security Lapse	120	(3)
Mis-Authorization Event Review Team's Report	123	(2)
Insights and Excursions	125	(17)
The Two Events: Tangential or Essential?	142	(2)
CHAPTER FOUR Charles Station: Transformer Trouble	144	(52)
An Account of a "Significant Near-Miss" on a Generator Step-up Transformer	144	(7)
Witnessing "A New Find"	151	(3)
Team Reports	154	(4)
The Reception of the "Organizational Effectiveness" Team Report	158	(4)
Insights and Excursions	162	(34)
CHAPTER FIVE Logics of Control	196	(44)
Three Logics of Control Culture	198	(5)
An Infrastructure of Conundrums	203	(6)
Control in Real Time	209	(4)
Doubt, Discovery, and Interpretation	213	(4)
Words, Meanings, and Deeds	217	(7)
Standing in the Way: A System of Claims	224	(6)
Crystallizing the Difference: Numbers and Values	230	(5)
Objective and Subjective, Technical and Substantive	235	(2)
Certainty and Ambiguity, Doubt and Discovery	237	(3)
CHAPTER SIX Intellectual Capital for Regulation and Self-Regulation	240	(43)
Controlling and Coordinating Knowledge	242	(6)
The Scope of Event Reviews	248	(9)
"Maintenance Is Going to Save You"	257	(5)
"Levels of Maturity"	262	(4)
Re-Imagining the Culture of Control in the Nuclear Power Industry	266	(4)
From Functions to Meanings: A Second Axis for Risk-Reduction	270	(6)
Into the Next Half-Century	276	(7)
APPENDIX ONE Senior Management Group at Overton Station	283	(3)
APPENDIX TWO Nuclear Power Plant Modes of Operation or Shutdown	286	(2)
APPENDIX THREE Study Description	288	(1)
Notes	289	(36)
Bibliography	325	(42)
Index	367