About the Book

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