Resumé

This paper explores organizational issues raised via a comparison of the Bravo
oil blowout in the North Sea and the Three Mile Island nuclear accident in
Pennsylvania. The organizations involved, their interconnections and interests in
each accident are compared. Six actor types are used as a classification system
for framing the comparison. The underlying issues bearing on allocation of effort
to pre-accident planning are also noted. Finally, a framework from this effort is
used for guiding the planning of operations for future accidents.

On April 22,1977, an offshore oil well went out of control in the Norwegian sector of the North Sea. From this time until well control at the Bravo platform was regained on 30 April, a maximum of 12,700 tons of oil landed on the sea. This oil blowout was the first major accident in the North Sea involving a producing offshore platform, although other non-blowout accidents have occurred there. It captured world-wide attention and signalledto North Sea oil industry and governments that oil blowouts can be experienced even though prevention in-depth and safety requirements exist. Prior to this accident, blowouts were viewed as 'impossible' in the North Sea. The Royal Commission of Inquiry, created to investigate this accident, reported that 'the underlying cause of the accident was that the organizational and administrative systems were on this occasion inadequateto safe operations'. In addition, it found that the 'accident to a large degree was due to human errors' and that while 'certain technical

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* I wish to acknowledge the financial support of the International Institute for Applied Systems Analysis in Laxenburg, Austria, which afforded me the opportunity to organize a research task on this topic and financed my interviewing of the principals involved. This paper does not necessarily reflect the views of HAS A or my current institute above.

weaknesses were present', they were only of peripheral significance for
the course of events' (Royal Commission of Inquiry, 1977, p. 4).

Almost two years later on March 28,1979, a series of events culminating in a nuclear plant accident with a partial core melt-down occurred in the United States. From this time until the initial danger subsided on 2 April, an unspecified but probably low amount of radiation was released into the environment. This nuclear accident was the first major accident in the United States, and it too captured world-wide attention and signalled to the nuclear industry and governments that nuclear accidents were a reality and something to be reckoned with, even though prevention in-depth and safety requirements exist. Prior to this time such accidents were also viewed as 'impossible'. The Presidential Commission set up to investigate this accident concluded that 'fundamental changes will be necessary in the organization., procedures, and practices - and above all -in the attitudes of the Nuclear Regulatory Commission and, to the extent that the institutions we investigated are typical, of the nuclear industry' (Presidential Commission, p. 7).

Given two similar conclusions stemming from tv/o dissimilar but major accidents, it would seem reasonable to compare some of the organizational administrative issues surrounding these accidents, particularly since both of these energy-related accidents have resulted in slowing down the production of new energy in an energy-short world. It may be surprising each of these accidents has resulted in public controversy and temporary moratoria on further development since in neither accident did significant off-site damage occur. The resulting oil slick at Bravo which escaped being contained did very little damage to marine life and no oil reached the Norwegian or Danish shores. The radiation releases at Three Mile Island (TMI) were largely contained and the overall health effects have been found to be minimal. There was also no loss of human life in either accident. Regardless of the minimal physical damages incurred, both accidents have spawned political moratoria for a variety of reasons: increased safety consciousness by the public, increased awareness of invisible and environmental damages, existing government emphasis on safety regulations, existing industrial 'propaganda' on the impossibility of major accidents, lack of familiarity with such accidents, increasing spread of large-scale energy production facilities, etc. While an investigation of these phenomena would be of interest, this paper does not attempt to do so. Neither does it attempt an analysis of the accident prevention systems surrounding these energy technologies.

Rather, its purpose is to look at possible lessons to be gained from a

comparison of the organizational responses for the managing of these two accidents after they occurred. No attempt will be made here to outline the sequence of events in these accidents or to discuss the significance of such events.¹ Certain human and technical features are comparable in these two accidents and interested readers are urged to compare them, but a total comparison is beyond the scope of this paper. Table 1 displays a comparison of certain technical features of these two accidents as background for this paper, but no description is included to elaborate on any of the listed items. Out of this organizational comparison it is hoped that certain lessons may be drawn that would be useful for further research into the organizational aspects of major accidents involving large-scale energy technologies. Certainly, the experiences of these two accidents highlight a need to focus on the organizational systems created to manage accidents, particularly in countries where national policies for public safety are emphasized.

1. The Actor Types Involved at Accidents

Given an inherent awareness of accident probability, why were these two accidents seemingly unexpected and the organization and administrative practices surrounding their management created ad hoc? Such a question can be partially studied by looking at the actors who are expected to respond to accidents. An actor's ideological foundation for safety and accident management as well as its communication and linkage to other social actors appear as important determinants of the adequacy of organized to large-scale accidents.

Any technology has a protective core of organizations or actors linked together by a common ideology or set of oversimplifications of shared knowledge and interests that supports that technology. An energy technology is no different since the technological expertise and resulting ideology required gives power to organized technical experts in private and public bureaucracies. Such influence is communicated to other actors,whether beneficiary or sufferer, via information used to foster public opinion to achieve the ends desired by the technocrats and others sharing the same values (Meynaud 1969). For example, while the setting of a safety standard directly involves the industry designing, manufacturing, supplying, using and servicing the technology as well as the regulator, other actors include unions, politicians, local governments, residents, consumers, rival technologists, other government agencies, research experts,etc.

perts,etc.Such a broad array of actors drawn into the setting of, say, a
safety standard can generate conflict because of differing perspectives and
hence ideologies (Fischer 1979).

This proposition has as its core the concept of actors or social groupings representing various organizations involved or wanting to be involved in the responses to safety and accident management. As responses to the accidents at Bravo and TMI showed, new organizations can be instantly created (as at Bravo) and new roles can be created by and for existing organizations (as at TMI). Major actor groupings that would appear useful in examining and comparing accident management roles and linkages at Bravo and TMI include the following:

1. The company(s) owning, operating, and servicing the technology;

2. The government agency (s) regulating the technology;

3. The response agency(s) which has responsibilities for managing
emergency situations/accidents (this agency can also be part of a
regulatory agency);

4. The inside experts from government agencies, research institutes,
companies and universities;

5. Those heterogeneous social groups impacted upon or potentially
benefitting or suffering from the technology and an associated
accident;

6. The exogenous and unorganized influential groups that an accident
such as politicians, outside experts, and media representatives.

These actor groupings are seen as a minimal actor configuration required for a comparison of the accident responses generated at Bravo and TMI. While each of these different actor groupings have different ideologies that affect goals, incentives, information, perceptions, and alternatives, the accident is the basis for their being bound together in some form of combined and linked management response. Their inconsistencies can be used, set aside, ignored or cancelled in order to meet the commonly perceived threat to their livelihood. No direct a priori organizational forms normally exist to integrate all of these actor groups; rather it has been the accident itself that was the integrating factor. Choices of organizational form and function have tended to evolve during the course of such accidentsas at Bravo and TMI. As such, the actual responses have been ad hoc, based upon experiences during the accident rather than being based upon normatively derived organizations and administrative practicesfrom

ticesfroma priori analyses. This ad hoc approach had the advantage of allowing access by certain impactees and exogenous actors into the accidentmanagement but it can lead to interference and wrong interpretationswithin management system itself and outside for the public at large. Thus a planned accident management system should account for the inclusion of seemingly external, but influential and involvedactor

Given that a large-scale, politically important accident can involve such actor groups as those listed above, the questions are: who are involved, and in what ways are they involved? In addition, the linkages between these actor groups for the purposes of on-site accident control, mitigation of its off-site consequences, and the giving and acting on information about the accident would be of concern.

In order to shed light on these questions, the actor involvement and interrelationships that evolved at the Bravo and TMI accidents will be presented. From these brief descriptions a schematic organizational form for each of these accident responses will be presented. Through a comparison these two evolved organizational responses, suggestions can be made about the outline of a more adequate organizational form for responding major accidents. However, this paper does not attempt to describe the individual actors responding to these two accidents. An earlier paper described the Bravo accident, the responding actors, their organizational form, and their key decisions (Fischer 1978).

2. Comparison of the Bravo and TMI Actor and Organizational Responses

This section of the paper provides the comparison of the actors involved in the Braco and TMI accidents. In addition, the organizational linkages between these actors are discussed. Each of the six actor types are used as the basis for this effort. Table 2 is the keystone in this comparison and has been designed to be self-explanatory so that only amplification of selected issues will be discussed in the text.

For the Accident Response Actor the significant differences between Bravo and TMI lie in its manner of creation and the degree of authority and centralization of this actor type. At Bravo an immediate ad hoc decision was made by the Minister for Environment to place all major regulatory and supportive actors within one Action Command under a single leader. While this response existed earlier in outline form, it had never been

implemented and was done so by oral authority within hours after notificationof accident. All on- and off-site public responses were placed under this single technocratic actor, and the Action Command was a direct representative of the central government so that no politicians had to participate directly in its decisions. The Action Command carried out its functions through the normal regulators and left the primary responsibility for management of the on and off-site consequences with the operator. In addition, all official statements released to the media were done through this one body which eliminated the possibilities for conflicting and speculative information from elsewhere within the government or the operator. Finally, the Action Command had a priori authority to take over the management of the accident from the operator if it was deemed necessary in the public interest.

At TMI this actor type was created ad hoc in the midst of the management the accident by the two top affected politicians, one of whom personally directed the key off-site responses. The organizational form was decentralized into three separate headquarters using political and technocratic actors with responsibilities matching their normal jurisdlctional An understanding of the accident and communications between these sets of actors thus became crucial, especially with increasing from the site of the accident. Oral authority was also used by these politicians in the creation of this form of response. Information given to the media was jointly done by the Governor of Pennsylvania and a designated representative of the NRC, the Nuclear Regulatory Commission, of whom were directing the key on and off-site accident management PEMA, the Pennsylvania Emergency Management Agency, which was given greater authority during the accident, became separated from the information flow from the Governor's Office during the latter stage of the accident.

Accident management was split among different actors because of the unfamiliarity with nuclear accidents, the slow recognition of the nature of the accident, conflicting information and recommendations from the NRC, the rising interests and conflicting information being presented in the media, the potential for public misinformation and panic, and the potential political impacts on governance and the future use of nuclear power. Three separate accident management and media information centers established ad hoc during the course of the accident. This arrangement was only possible because of the action by the State Governor the U.S. President who acted to limit the sources ofinformation and to consolidate the supporting agencies. These centers included:

1. The on-site accident center at the TMI plant was supplemented by
headquarters NRC staff where one man became the source of all
technical and on-site information;

2. The off-site accident management center in the State Governor's Office which coordinated all state and federal responses, and was the source of information on evacuation and other protective measures;

3. The President's Office coordinated the federal agency responses
for emergency relief and gave out information on this effort.

The direct responsibility for on-site management of the nuclear accident became mooted during its course because of the increasing involvement of the NRC, the Nuclear Regulatory Commission, in the cooling down of the reactor. No a priori authority existed for the NRC to take over the management of the plant from the NRC licensee-operator. In addition, the operator was requested not to release information to the media and it was not present at the press briefings.

The Normal Regulators at Bravo and TMI played different roles in the management of these accidents. The crucial differences are that the NRC headquarters initially took an ad hoc active role in the accident at a distance, and later at TMI when designated to do so by the U.S. President. Accident information gained in Washington from the site generated considerable and hasty recommendations which, in turn, created misinformed advice to off-site managers and speculative statements to the media. The NRC role at the site contributed to its on-site management while the NRC in Washington created needless anxieties among off-site managers and the general public. Information flow between the NRC Regional and Washington Offices is not clear from accident accounts. No a priori scientific knowledge seemed to surface within the NRC for responding this multi-faceted accident or to understanding the nature of the hydrogen bubble. This combined lack of scientific knowledge and appropriate responses was a shortcoming and should have acted as a brake on hasty and speculative statements both to accident managers and the media (Presidential Commission, 1979, p. 39-40).

During the Bravo accident the on-site regulator, the Oil Directorate, played only a passive role with the operator by checking and assessing their prospective plans for controlling the accident. This regulator then advised the Action Command on the quality of the plans as presented. The off-site regulator, the Pollution Control Authority, played a supplementaryrole that it specified the operator to use mechanical pollution

control devices and aided Phillips in finding and using them.

The Operators at Bravo and TMI each had primary responsibility in preventing and responding to accidents. Each operator responded similarly protecting their employees and physical plant, by calling in industrial to supplement their efforts and by notifying and cooperating with government regulators and accident managers. Also, both operators cooperated with the wishes of the governments' accident response actor with regard to the media. Neither operator relied on previously developed assessments of alternatives in responding to the particular set of events confronting them, including preventing escalation to the accident level as well as responding to it. Accident management was not a priority for these two operators.

The possibility of both of these accidents should have been expected. However, in both cases the supervisory and operational staff did not respond correctly while the accident was still preventable. Once the accident had occurred, experts from elsewhere in the industry occupied key roles in bringing the accident under control.

Phillips Petroleum had the primary responsibility of preventing and responding to the Bravo accident. This responsibility existed even though the accident occurred during a time of transition from few preparations to moving toward adequate preparation for mobilizing this responsibility. Thus it would seem that the government regulators would have had some: a priori role or means of supplementing the operator's existing responses before the operator was fully capable of responding to an accident in the required manner. The reasons given for not having such supplementary postures a priori was the hope that no accident would occur during the interim, the requirements having already been levied on the operators, and the concern for diluting the operators' responsibility.

Other oil companies operating in the Norwegian sector of the North Sea did not come to the aid of Phillips in this accident. Although a cooperative plan existed among the oil companies, it was not followed. On the other hand, at least one offer from the British sector was received and accepted. Apparently, a fear of future government responses toward oil development the oil companies responding to Phillips' plight as well as the government's decision to ignore the use of chemicals, which was the only alternative the oil companies could immediately use in a joint response. now exist for inter-company responses to accidents based on the use of mechanical means for pollution control.

At TMI the company itself had the primary responsibility of responding
to the accident as long as the status of the accident and its consequences

were contained within the perimeter of the plant site. The plant staff summoned technical engineers from its parent company for operation efforts in containing the accident. In addition, the plant supervisor brought in representatives from Babcock and Wilcox, the designers and constructorsof reactor cooling systems, their control, and their instrumentation.Finally, a later stage in the accident, aid was requested from the nuclear industry, which responded by creating an ad hoc advisorygroup of representatives from other private nuclear plants. Because the consequences of the accident went beyond the plant itself and into the adjacent environment and beyond, the plant supervisor also notified the Pennsylvania Emergemcy Management Agency (PEMA), the regional office of the NRC, the local county, the parent company, the Brookhaven national laboratory, the Pennsylvania Bureau of Radiation Protection, and the State Police. The supervisor also dispatched on and off-site radiation monitoring terms.

The Experts used in responding to each of these accidents had similar tasks: control the accident, track and predict the radiation cloud/oil slick, and help control the consequences. At Bravo no a priori scientific roles for experts had been developed, and so had to be initiated by the scientists, while at TMI scientific roles developed for government nuclear facilities were transferred on request to the TMI situation. However, at Bravo, scientists generally agreed on the predictions and degree of adversity of the oil slick while at TMI considerable disagreement existed over the nature and consequences of the accident and its radioactive emissions. Industrial experts were directly involved in controlling the accident itself, while government experts concentrated on the bubble and off-site impacts. priori and integrated roles had not been developed for these actors.

The total reliance on a locally untried single foreign outside expert for the key role of regaining control at Bravo could appear as a weakness in an effective accident management system. While the Red Adair Company has a world-wide reputation within oil company circles, the vast majority of its experience rests with killing blowouts on land where access to and space for amassing equipment to kill the blowing well is always available. The design, height and complexity of the larger North Sea offshore platform the use of capping procedures. Therefore, a probability for prolonged accidents exists in the offshore and localized experience in developing internal, integrated expertise has been suggested.

Impactees for these two accidents were quite different: Bravo affected
marine life and potentially threatened coastal communities via an ugly

mess, whereas TMI potentially threatened area residents' lives and health via an invisible cloud. However, in each of these accidents no major adverse impacts occurred to workers, residents or the biological environment.In one would conclude that the off-site damages were nil in both cases. A priori roles were underdeveloped for potentially affected residents, and information links for most impactees were via the media.

Assumed exogenous actors at Bravo and TMI became increasingly involved during the course of these two accidents. Politicians were essential in both of these accidents; however, the immediate appointment and confirmation of politically delegated authority at Bravo ensured the role of the Action Command as the accident manager. At TMI the two top politicians had to intervene during the accident to bring order out of seeming chaos created via conflicting information and recommendations. Site visits were made by the top politicians in both countries.

The media were significant in relaying information to area residents, national citizens, and the world at large. The media consisted of local, national and foreign representatives, all of whom served different interests and made different demands on information sources. No a priori public information roles and facilities were developed before these accidents occurred. Consequently, both information sources and quality contributed media confusion, particularly at TMI. Media representatives assigned to cover these two accidents did not have a priori technical knowledge to judge the content of the information nor to discern useful questions to be put to accident managers.

Outside experts used both of these accidents as vehicles to convey their views to the media on the representative technologies and their broader public impacts. Such views were used by the media for a variety of reasons, including lack of confidence in the accident managers' information. reported views contributed to public alarm during the accident and to the decisions for temporary moratoria made by the politicians after the accident.

Foreign observers were present at each of these accidents, and their demands for information were high because of the actual and perceived consequences in their respective countries. At Bravo foreign observers were present throughout the accident and observed the conduct of the Action Command in its deliberations. In addition, foreign observers were present in aircraft tracking the direction and extent of the oil slick. Finally, foreign groups played essential roles in the pollution control effort to contain and capture the oil slick. The Bravo accident resulted in closer cooperation between Norway and the United Kingdom in the post-accidentphase

dentphasefor the planning of integrated accident management responses. At TMI foreign observers were present at the NRC Washington office during and after the accident, and afterward at the plant itself. In addition, international agencies have deliberated over the implications of both of these accidents.

Figures 1 and 2 represent schematics which group the six actor types into the pre-accident management system, the ad hoc organized responses, the unorganized accident responses. These three sets of accident responses existed at both Bravo and TMI and could, therefore, be expected to exist in future major accidents. Together these three sets of responses constitute the overall ctccident management system.

The arrangement at Bravo as shown in Figure 1 shows the central role of the accident manager. Even though it was established ad hoc it functioned well in its relations with the operator, normal regulators and politicians. Because the normal regulators were part of this ad hoc accident management and because on and off-site responses were under its authority, a prolonged accident would not have deterred from this organizational arrangement.

The organizational set-up at TMI in Figure 2 shows a dispersed arrangement existed at the end of the accident. At the beginning of the accident, conflicting information sources and a lack of understanding of the nature of the accident led to a loss of credibility publically to the operator and politically to the regulator. These problems led to a threeway of responsibility: an ad hoc on-site manager was created; the Governor's Office was used to direct off-site responses; the President's Office directed federal agency emergency support. Had the accident persisted time, this arrangement could be expected to be further centralized one authority handling all responses.

3. Accident Management Actors and Organization

Certain experiences with those responding to the Bravo and TMI accidents been briefly described and compared. The responses of the six actor types which were used as the thrust for this paper can now be collated as the basis for stating 'conclusions'. These 'conclusions' should not be viewed as absolute, but as interpretations of the responses to the two accidents. Certainly, these 'conclusions' are issues that have been raised through the responses of these actor types and as such warrant discussion beyond this paper.

One major conclusion or issue is the lack of a priori roles for accident management by all of the actor types involved. For both Bravo and TMI even the Accident Response Actors were not prepared for immediate active involvement both on and off-site. While a major Norwegian response had been legislated and was being prepared, no a priori plans existed during the interim before the planned system could be completed. The NRC Washington Office, on the other hand, did not have preparations for active involvement with appropriate backup in an uncontained accident. The lack of agreed a priori roles also extends to the planned use of the normal regulator, the operator, industry and government experts, scientific experts, the politicians, the media, the outside experts, and those impacted upon by the accident.

Little foresight for active a priori accident management and supporting actor roles seems to stem from accidents being viewed as preventable. While both the Bravo and TMI accidents were found to be wholly preventable,still two accidents happened. Thus, one must conclude that preventable accidents cannot always be prevented and that a priori roles must be developed for expecting the unexpected. In addition, since transition periods always exist, it would seem important for alternative a

priori roles also to exist for ensuring effective responses, regardless of the
posited roles at the end of the current transition.

Accident management bodies are also temporary substitute decisionmaking and these actors were prominent in both accidents, particularly Bravo with its ad hoc Action Command for overall management the Red Adair Company which managed the accident control process. However, even at TMI, substitute decision-makers included the ad hoc active roles of politicians and the ad hoc industry and regulatory responses. The use of substitute decision-making actors raises such questions authority, responsibility, liability, appropriate alternatives, and future working patterns, all of which impact on the relationships between the operator and the normal regulator.

Reliance on substitute actors of any type, whether decision-makers or supporting experts, can lead to difficulty in the post-accident phase. Once the accident is over or otherwise under control, the substitute actor has completed its task, leaving the normal regulator and operator to cope with and adjust to the consequences of its actions. In addition, the appointment of a temporary investigatory actor in the post-accident phase existed at both Bravo and TMI, and such an actor can further disrupt the regulatoroperator If substitute actors work through or with the normal regulators and operators, then accident management would be more reinforced an issue requiring greater attention by both regulator and operator. Also, a smoother transition to the post-accident phase would ensue as well as a strengthening of the prevention or pre-accident phase.

Previously assumed exogenous actors were involved in both of these accidents. Politicians, the media, outside experts and foreign observers all played important roles during and after these two accidents. No a priori roles existed for these actors, and one can conclude that they were initially viewed as exogenous by all pre-accident actor groups. However, both Bravo and TMI showed that these actor types can occupy significant roles in accident management and should therefore be integrated into the preaccident, and post-accident phases. Consideration of these actors assessments of their responses before an accident can lead to greater management effectiveness and reduced stress by on- and off-site accident response actors during the accident itself. Lack of these exogenous being included a priori led to unforeseen political consequences on later energy development, more alarming media reports, and a heightened anxiety among the general public.

An additional conclusion appears to be the necessity for a centralized
organizational form as near to the scene as possible for responding to

accidents. The TMI accident showed the confusion and loss of political and public credibility that can occur from a decentralized system that is at varying distances away from the actual accident. In addition, such confusioncan abetted through ad hoc arrangements to create a different organizational form during the accident, including the move to a more centralized system nearer to the accident. The loss of credibility can also extend well beyond the accident itself to limit the role of the use of the technology in question, as has occurred with the current moratorium on nuclear energy in the U.S. and elsewhere.

On the other hand, the Bravo accident demonstrated that a centralized system where accident response actors and normal regulators are merged together into one body can be a workable arrangement. Under this form, media information sources, directions and advice to the operator, as well as advice to impactees and politicians, are all centralized. In this way, both political and public confidence could be maintained even in the face of an evolving or expanding accident with an uncertain outcome.

Another major conclusion from this overview of the Bravo and TMI accidents is the need for research based on systems analysis using social scientists as an integral part of the research process. Any accident management is based on individual and organizational actors, and the cause of the Bravo and TMI accidents has been investigated and attributed to weaknesses among the actors responsible for preventing these two preventable accidents. Viewing these accidents from a wider perspective based on a recognition of at least these six actor types, as suggested in this paper, requires a systems point of view based on social science. The more that is left out of an analysis, the less that is subject to change; and both the Bravo and TMI accidents reveal that the fundamental human and organizational and values had not been previously subject to study and hence to change for preventing these two accidents. Systems analysts and social scientists should examine their own implicit assumptions of doing research and integrate their roles into a more applied focus on accidents and their social consequences. Certainly, such research can and should be an integral part of the premises used for creating a total accident management system.

Thus the extent of actual damage to impactees cannot be viewed as the most significant factor in these accidents. Both at Bravo and TMI the off-site damages sustained were nil, yet both accidents resulted in political decisions for temporary moratoria for further development. Technical defense in depth for containing the consequences of an accident only appears to reduce the immediate effects on impactees. The politicians,

media and general public can generate long-range effects for temporarily stopping further oil and nuclear energy development, regardless of the energy benefits involved. Therefore, wider creation of a priori consultations,open flows of information, and participatory roles for heretofore exogenous actors may be useful for reducing the political consequences of moratoria on energy development.

4. Recommendations for Organizing for Accident Management

Figure 3 is an attempt to portray an accident management system that displays a priori roles and linkages based on a centralized organizational form for the actor types discussed in this paper. Such a management system recognizes roles for the responses of all actors generated by a major accident before it happens. This a priori framework is important for setting the formal basis for necessary ad hoc actions and informal bargaining arise during an accident. The organizational system must be arranged so that the roles occupied and the performances in these roles are rewarded or penalized by an incentive system at least equal to the severity of the consequences expected in an accident. Separation of roles in the pre-accident phase and ad hoc emergence of new roles in the accident phase imply that individual incentive systems can color accident responses than the needs of the accident as a whole. A more rational a priori system with an integrated set of incentives for integrated management would seem to be the basis for more effective accident management. Additive individual capacities to respond to an accident cannot be expected automatically to fulfil the needs for adequate responses. a figure suggests that because ad hoc and unorganized or exogenous actors will emerge and become involved with a previously organized system in a major accident, it is important to integrate their expected (and unexpected) responses into a total accident management system.

Regardless of the formal creation of a priori roles among the various actors that can be expected to become involved in a major accident, one encounters professional ideologies from such actors that can inhibit their operation. One such bias is that regulators and operators become enamoredwith third-party benefits of energy and tend to lose sight of the third-party costs involved. For example, the responses to intermediate multi-cause accidents involving the man-machine interface have not been the subject of much study. One reason for this oversight is that the

technological prevention of a total or massive accident has occupied much of the research resources. Many references contrast a total accident with total prevention, with the result that little is known about intermediate accidents and their appropriate, alternative intermediate responses.

When it comes to the ideologies surrounding accident management, my hypothesis is that the greater the implicit consensus among actors, the greater my concern for gaps in their responses. Each organization has a dominant professional bias and its own collective wisdom or 'mindset'. Such devices are important for minimizing normal uncertainties internal to the individual actor, but these values and assumptions also lead to greater uncertainties within the overall accident management system. Explicit and implicit value differences exist between each of the actors that can be expected to be involved in responding to a major accident. The more the

implicit values and assumptions separating these actors can be discovered and questioned, the more differences and hence gaps between actors will appear. Such a questioning can lead to greater self-examination both individually as an actor and collectively as part of an accident management system. However, the more fundamental the issues and need for selfexamination,the is the willingness by each to do so, especially with other actors in the management system. Thus the externally appointed investigatory body in the post-accident phase plays a very essential role in requiring this questioning process and in attempting to see the pre-accidentphases as a system of inter-connected responses. The real need, however, is to create and structure this fundamental questioning process in the pre-accident phase rather than after an accident occurs.

Figure 3, of course, is a static picture and some process for questioning the values inherent in developing such a system is necessary. A dialectical planning process is one way of attempting to create a more comprehensive and realistic accident management system. Such a process can lead to the fundamental questions of which actors should be involved in the system, how they should be involved, and which (unexpected) responses should be planned for before they occur. The pre-accident planning approach suggested here could prove useful in determining a priori sources of conflict in ideologies and using them creatively in the design of the entire management system. Certainly, a dialectical planning approach is one way to overcome the existence of a rigid 'mindset' or attitude which the Kemeny Commission found to be at the core of the issues surrounding the TMI accident. In addition, one organizational expert has noted: '. . . v/e know how to cope with continous change but not with discontinous change ... when discontinuities do occur, they upset things in a big way because then the underlying assumptions of the past no longer apply.' (Handy, 1980, p. 115-6.)

One attitude that I have found prevalent among regulators and operators in my research on these two accidents in the oil and nuclear industries has been that of uniqueness. Each accident was viewed as 'impossible' becauseof employment of safety technologies in-depth and generally superior safety requirements when compared to the past or to some other industries. In addition, each accident after the fact was viewed as 'unique' or as the result of a particular one-time configuration of weaknesses that in combination led to the accidents. Thus it was assumed that such weaknesseshad been accounted for and that organizational-administrative weaknesses would no longer be an issue. I would suggest that the ideology of uniqueness is a myth and that the experiences of these two accidents

show a comparative systems analysis of accident management would
pro ve useful.

Why should the management of near and actual accidents have been down-played in the organization and administrative practices surrounding the design, construction, licensing, operation, and servicing of offshore platforms and nuclear reactors? Such a question can be partially studied via two further questions:

1. What is the fundamental professional ideology, administrative
outlook or attitude toward safety and accident management by the
industry and its regulators?

2. How are complex questions of safety and accident management
formed and put forth or merchandised to others by the industry
and its regulators?

This short paper could not hope to approach these two significant
questions, but it is my hope that subsequent research on actor behavior
can bring greater analysis to bear on these questions.

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NOTE

1 For descriptions of the accidents and the sequence of events for each accident as well as for the discrepancies in the underlying preventive systems between the regulator and regulatee, the investigative reports of the Royal Commission of Inquiry for Bravo and the Presidential Commission for Three Mile Island as listed under the references at the end of the paper.

REFERENCES

I. Interviews with the following individuals:

A. Bravo accident:

1. Hans Chr. Bugge, Director of Action Command for the Bravo blowout and Director of
Pollution Control Authority.

2. Arne Flikke, Director of Oil Pollution, Pollution Control Authority.

B. Three Mile Island accident:

1. Robert Arnold, Director of Recovery Operations at TMI, Metropolitan-Edison and
General Public Utility.

2. Harold Collins, Asst. Director of Emergency Preparedness, Nuclear Regulatory Commission.

3. Oran Henderson, Director of Pennsylvania Emergency Management Agency.

4. Dudley Thomson, Asst. Director for Inspection and Enforcement, Nuclear Regulatory
Commission.

11. Attendance at briefing arranged for foreign observers by the Nuclear Regulatory Commission,
21-22, 1979.

111. Attendance at Congressional hearings:

1. Subcommittee on Energy Research and Production, House Committee on Science and
Technology, May 23, 1979.

2. Subcommittee on Energy and Environment, House Committee on Interior and Insular
Affairs, May 24, 1979.

IV. Written testimonies and other references:

1. The Bravo Blowout: The Action Command's Report, Ministry of Environment, Oslo, 22
December, 1977.

2. Commission of Inquiry, Uncontrolled Blowout on Bravo, Oslo, 10 October, 1977.

3. Ministry of Petroleum and Energy, The Uncontrolled Blowout on the Ekofisk Field (The
Bravo Platform), Storting Report No. 65, Oslo, 1977-78.

4. D. W. Fischer, A Decision Analysis of the Oil Blowout at Bravo Platform, Energy: The
International Journal, Vol. 3, 1978, pp. 785-797.

B. Three Mile Island Accident:

1. Babcock & Wilcox, Testimony before the Subcommittee on Energy Research and
Production, House Committee on Science and Technology, May 23, 1979.

2. Ad Hoc Population Dose Assessment Group, Population Dose and Health Impact of the
Accident at the Three Mile Island Nuclear Station, Bureau of Radiological Health, May
10, 1979.

3. J. T. Con way, Testimony before the Subcommittee on Energy Research and Production,
House Committee on Science and Technology, May 23, 1979.

4. H. R. Denton, Testiomony before the Subcommittee on Energy Research and Production,
committee on Science and Technology, May 23, 1979.

5. Det Norske Veritas, Review of the Three Mile Island Nuclear Power Station Accident,
Oslo, October 1979.

6. H. Dieckamp, Testimony before the Subcommittee on Energy and Environment, House Committee on Interior and Insular Affairs, May 24, 1979, and Testimony before the Subcommittee on Energy Research and Production, House Committee on Science and Technology. May 23, 1979.

7. J. G. Herbein, Testimony before the Subcommittee on Energy and the Environment,
House Interior and Insular Affairs Committee, May 24, 1979.

8. C. Kepford, Testimony before the Subcommittee on Energy Research and Production,
House Committee on Science and Technology, May 22, 1978.

9. W. S. Lee, Testimony before the Subcommittee on Energy and Environment, House
Committee on Interior and Insular Affairs, May 24, 1979.

10. S. Levine, Testimony before the Subcommittee on Energy Research and Production,
House Committee on Science and Technology, May 22, 1979.

11. G. P. Miller, Testimony before the Subcommittee on Energy and Environment, House
Interior and Insular Affairs Committee, May 24, 1979.

12. President's Commission (Kemeny Commission), The Accident at Three Mile Island,
Washington, D. C, October 1979.

13. Lt. Gov. Scranton and Col. Henderson's Interview with the French Delegation Concerning
Mile Island, Mimeo, Harrisburg, Pa., May 2, 1979.

14. W. W. Scranton 111, Testimony before the Subcommittee on Energy Research and

Production, House Committee on Science and Technology, May 23, 1979.

C. Other materials:

1. R. Goodin and I. Waldner, 1979. 'Thinking Big, Thinking Small, and Not Thinking at
All', Public Policy 27, pp. 1-24.

2. D. W. Fischer, 1979. 'Policy Issues in Pollution Standard-Setting', ed. by G. T. Goodman
W. D. Rowe, Energy Risk Management, London: Academic Press.

3. H. P. Green, 1973. 'Nuclear Power: Risk, Liability, and Indemnity', Michigan Law
Review 71, pp. 479-510.

4. C. Handy, 1980. 'Through the Organizational Looking Glass', Harvard Business Review
58, pp. 115-116.

5. O. R. Holsti, 1978. 'Limitations of Cognitive Abilities in the Face of Crisis', Studies on
Crisis Management, ed. by C. F. Smart and W. T. Stanbury, Vancouver: U. of British
Columbia Press.

6. J. Meynaud, 1969. Technocracy, New York: Free Press.

7. I. I. Mitroff and J. R. Emshoff, 1977. 'On Strategic Assumption Making: A Dialectical
Approach to Policy Analysis', mimeo, U. of Penna., Phila.

8. W. D. Reekie and N. C. Hunt, eds. 1974. Management in the Social and Safety Services,
London: Tavistock Publications.

9. Task Force on Nuclear Safety, TVA Nuclear Program Review, Tennessee Valley
Authority, Knoxville, May 1979.

10. Guide and Checklist for Development and Evaluation of State and Local Government Radiological Emergency Response Plans in Support of Fixed Nuclear Facilities, U.S. Nuclear Regulatory Commission, Office of International and State Programs, NUREG-75/111.

11. Planning Basis for the Development of State and Local Government, Radiological Emergency Response Plans in Support of Light Water Nuclear Power Plants, U.S. Nuclear Regulatory Commission and U .S. Environmental Protection Agency, NUREG-0396, 520/1-78-016.

12. E. Wenk, Jr. 1979. Margins for Survival: Overcoming Political Limits in Steering
Technology, Oxford: Pergamon Press.

13. A. Wildavsky, 1979. Speaking Truth to Power: The Art and Craft of Policy Analysis,
Boston: Little, Brown.