No Excuses, Thank You Very Much

"It is unlikely that even if you had full valve closures, that you would have immediate impact on the fuel coolant, (but) that was not apparent until some additional detailed analysis was done. The operator was told to do something on one system and actually did something completely different on another system. That's a very unusual type of error to see. So whenever you see a very unusual error in a nuclear reactor control room you have to treat this very seriously regardless of ... what the causes would be.
"Nothing actually happened, but there was certainly potential for something more serious to happen and therefore it needs to be thoroughly investigated."
Peter Elder, director-general, Canadian Nuclear Safety Commission

This doesn't represent a simple oversight, a human error in receiving and processing an order incorrectly that would impact some innocent enough piece of machinery. This was a Chalk River nuclear operator erroneously closing a vital pumping system that cools heat generated within the reactor core. This was an incident that could have had catastrophic consequences. In fact, just about any kind of mindless human error in tending to the serious business of operating nuclear reactors can be fraught with danger.

"This event had no safety consequences to workers, the public or the environment. Cooling to the reactor was maintained at all times", assured the vice-president of operations and chief nuclear officer for Atomic Energy of Canada Ltd. "We have and we will continue to operate the NRU reactor safely", he assured an enquiry undertaken by a six-member CSNC commission.

AECL, he assured the hearing, is treating the incident in the manner to which the seriousness of the event required, at "Significance Level 1", signifying the highest level of alert and investigation. "We understand the events and take corrective action". The CSNC panel was interested in hearing how the control room operator so incorrectly construed his order that he closed a series of valves that he should never have touched.

"When we have a human performance event that deals with a reactor operation, we need to take this event very seriously and we've done so", responded Randy Lesco, chief nuclear officer for AECL.

Serendipity had it that a senior official was in the control room with a visiting authority from the World Association of Nuclear Operators, undergoing a peer review. That senior official just happened to sight the error and swiftly reversed the valves before they fully closed. Simultaneous to that action a "low-flow" alarm sounded, alerting everyone to the situation.

"There would have been no consequences to the fuel if this event that progressed to full-valve closure for many hours", in the event that no corrective action had been taken, the senior director of NRU operations confidently informed the enquiry panel. Of course, because of the alarm alerting to the event taking place, it would have been highly unlikely that the 'event' might have progressed without attention paid to the unfolding situation.

Needless to say, the reputation of the Chalk River nuclear operation and the expert professionalism of staff must surely have taken a hit under the watchfully enquiring eye of the visiting official from the World Association of Nuclear Operators. Clearly, the peer review would have established that an event would be cited representing operator error of a significant magnitude. The result of which would be a citation of poor operation quality.

Along with the admonishing statement aimed at Atomic Energy and the CNSC staff by CNSC President Michael Bindman to the effect that the incident should have been subject to full public disclosure, the event does not throw a very impressive light on the professionalism of the nuclear operators. "Our observation always is you're way ahead if you're the one that's first to report on the event rather than the media", they were chided.