Three Mile Island Even more detail can be added to this Cause

Harrisburg, Pennsylvania A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page.
Map as the analysis continues. As with any
March 29, 1979 investigation the level of detail in the analysis is
based on the impact of the incident on the
The partial meltdown of a core at the nuclear power plant at Three Mile Island is one of the most well organization’s overall goals.
known engineering disasters in US history. Luckily, no one was injured and there was no significant
environmental impact, but the potential for major issues was very real. Three Mile Island also had a
huge impact on the nuclear industry and required a major clean up effort.

Performing a root cause analysis of historical incidents is useful because there are a number of
lessons learned that can often be applied across a variety of industries.
As is true with any complex system, there were many causes that contributed to the Three Mile Island
No heat is No flow to
incident. At the most simplified level, cooling water flow was stopped to the primary system (the Primary
removed from secondary side Main feedwater
(nuclear) plant
nuclear portion). The primary system then started to heat up, increasing the pressure to the point that steam of steam pumps trip off
heats up
a relief valve lifted. The relief valve then failed to reseat and a large volume of coolant was lost. The generators generators
Pressure in Evidence: Plant Evidence: All
core eventually overheated because it was uncovered due to the loss of coolant. Evidence: No other
feedwater pumps
Primary plant indications heat exchangers in
systems turned off, plant
goes up
indications
AND
Pressure relief Evidence: Plant
valve indications
automatically Primary plant is
Production Plant
opened AND
closed system
Goals permanently
Evidence: Rapid
Impacted shut down pressure drop Safety feature, Evidence: Plant design
valve opens at
set pressure
Potential for Partial limit
Safety Goals Reactor core Large volume of
many serious meltdown of
Impacted uncovered coolant lost AND
injuries reactor core
Valve didn't
Evidence: Post accident
reseat as
investigation showed about Another factor that contributed significantly to the Three Mile Island incident was
Environmental one half of fuel had melted designed
Potential for operator action during the casualty, which occurred over several shifts. Had
Goals Pressure relief
serious impact operators been able to understand the status of the plant in a timelier manner, the
Impacted valve remained AND
open plant could have been put into a safe condition.
Evidence: Accident could
have resulted in major Possible Solutions:
Evidence: Loss of large
release of radiation to
amounts of coolant, coolant Modify design of At first glance, it’s easy to stop at this point and use a term like “operator error”, but a
environment control room
overflowed tank the valve thorough analysis requires more digging. Even if the technology being considered is
overflowed into.
radically different than a nuclear power plant, there are many lessons that can be
Operators didn't
know valve was learned from studying how the control room design impacted the operator actions
open during the incident.
Evidence: Operator
statements and actions The design of the control room significantly contributed to the operators’ inability to
identify plant conditions. The control room was huge with hundred of instruments to
monitor, some of which were on the back of the control panels and couldn’t be
viewed in the normal watch standing locations. Dozens of alarms, both audible and
Cause Map flashing lights, went off in a very short period of time without any obvious priority.
Detail Level
The alarms continued throughout the casualty and the sheer volume of information
was nearly impossible to interpret accurately.
Why?
Many industries continue to benefit from the lessons learned from the design of the
Investigate Problems. Prevent Problems. Effect Cause control room.
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