On July 19, 1989, United Airlines Flight 232, a DC-10, crash-landed on a runway at the Sioux City, Iowa airport.
According to the subsequent report by the National Transportation Safety Board, the accident was triggered by a titanium fan disc that was part of the plane’s No. 2 engine. That titanium disc, which of course spins at a very high speed, had a microscopic manufacturing defect that had, over time, created a hairline crack. That crack eventually caused the disc to break apart in mid-flight, and pieces of the disc spun out like shrapnel and cut through all three of the plane’s hydraulic systems, destroying them. On small planes, parts such as rudders, stabilizers and ailerons on the wings may be controlled by cables and mechanical connections directly to the pilot’s steering yoke, foot pedals, or other cockpit controls. But on a commercial jet like a DC-10, those surfaces are so large, and the forces exerted on them so great, that hydraulics are necessary to move them. When pieces of the fan disc cut through all the hydraulic lines, the pilots could no longer control the airplane by means of ailerons, rudder and stabilizers. Still, in a truly remarkable feat, the pilots, using only the engine throttles, managed to steer the crippled plane onto a runway at Sioux City airport. Of the 296 persons aboard, including the crew, 185 survived.
The Flight 232 disaster is an example of how the failure of one complex system (turbines) can interfere with or even completely disable one or more other complex systems (hydraulics) with catastrophic effect.
On February 9, 2022, the Inspector General of the Nuclear Regulatory Commission released a report (NRC Inspector General’s Special Inquiry Into Counterfeit Fraudulent and Suspect Items in Operating Nuclear Power Plants, or the “Report”) stating that:
• The NRC lowered its oversight standards for ensuring that counterfeit, fraudulent and suspect parts were not used in U.S. nuclear power plants;
• Fake parts are present in most, if not all, U.S. nuclear power plants;
• Persons within the industry informed the NRC about the use of these fake parts; and
• The NRC failed to appropriately address this problem.
The Report states that the IG is “aware that the NRC staff does not have a direct role in identifying counterfeit parts and preventing their use in a nuclear power plant.” (Report, pg. I). Well, if not the NRC, then who does that job?
But wait, it gets better (i.e., worse). Counterfeit parts are tracked only on a voluntary basis, if at all, and the NRC doesn’t require nuke plants to report use of counterfeit parts “…unless a situation rises to the level of being a significant condition adverse to quality, or a reportable issue” under applicable regulations. (Report, id.) Stated differently, don’t bother the NRC until something bad happens.
The Report also states that “[counterfeit parts are safety and security concerns that could have serious consequences in critical power plant equipment required to perform a safety function.” (Report, at ii).
Gee, do you really think so? That sentence could have been lifted out of the Chernobyl or Three Mile Island autopsies.
The NRC has an “Allegation Manual” and a process for reports about counterfeit parts through its Allegation Review Board.
According to the NRC’s own Management Directive (MD) 8.8, Management of Allegations, “anyone should feel free to communicate any safety concern to the U.S. Nuclear Regulatory Commission.” (Report, pg. 9). This manual contains procedures for handling such allegations.
Oh, well, that ought to do it, right?
Wrong. The Report goes on to state that although allegations about counterfeit parts in nuke stations had been made for the past ten (yes, 10) years, “…the NRC did not investigate or pursue any substantive actions regarding [the allegations about counterfeit parts],” and classified [these] concerns about counterfeit parts as “non-allegations.” (Report, id., pg. I , emphasis added).
Holy Terminology, Batman! What is a non-allegation? That’s a tough question, so let’s begin with an easier one. What is an “allegation”?
MD 8.8 defines an “allegation” as:
a declaration, statement, or assertion of impropriety or inadequacy associated with NRC-regulated activities, the validity of which has not been established. (Emphasis added.)
Report, pg. 9
That sounds more or less reasonable. But that’s not really how it works at the good ol’ NRC. What the alleger may have thought was an allegation doesn’t actually become an allegation until whatever was alleged goes through a multi-level initial consultation process by NRC staff to determine that whatever was alleged is the real McCoy, an allegation allegation.
If you think that’s confusing, try this tour de force of sanctimonious bureaucratic phraseology, drawn from the NRC’s Allegation Manual:
If, after this initial consultation, it is unclear whether information provided by the concerned individual constitutes an allegation, it is appropriate to discuss the information at an ARB [Allegation Review Board] to obtain a decision. If the ARB cannot reach a conclusion as to whether the concern in question should be processed as an allegation, the [agency allegation advisor] should be consulted. Some regions/offices assign an allegation number to such issues and then recode the item in the AMS [Allegation Management System] database as a non-allegation if the ARB determines that the issue is not an allegation. Some regions/offices document the issue on allegation process forms but withhold assigning an allegation number until the ARB has reached a conclusion. Either approach is acceptable.”
(Report, pgs. 9-10; emphasis added).
So even though an “allegation” is still an “allegation” if its validity has not been established, the NRC’s own procedures describe how it sweeps uninvestigated allegations under the rug.
The Report goes on to describe one case in which an alleger notified NRC staff about counterfeit part concerns at a specific nuke plant (Seabrook Station in New Hampshire) by letters, emails, phone calls, and even discussions at public meetings, all over the course of ten (10) years.
The NRC determined that the alleger’s allegations were not really “allegations.” It classified the allegations as “non-allegations” and did nothing.
So, if you think that the NRC is supposed to be protecting the public by ensuring the safe operation of nuclear plants, you might be surprised to find that it has borrowed its policy toward fake and counterfeit equipment in U.S. nuclear plants from Alfred E. Neuman of Mad Magazine fame: “What, me worry?”
A nuclear generating station has millions of parts that make up different complex systems that enable it to function as designed. An accident caused by a counterfeit part in one system at that station might be confined to that system, and it could be something from which a fast recovery is possible. For example, if the pieces of the disintegrating fan disc on United Airlines Flight 232 had been contained within the cowl of Engine No. 2, its own system, the hydraulics would not have been cut and the airplane might well have landed safely and without any loss of life.
But an accident due to a counterfeit part in one system at a nuke station could affect one or more other systems, a cascading effect that results in a grave disaster. Given that an accident at a nuke station could render a populated area in the U.S. uninhabitable by humans for more than 10,000 years, one might be forgiven for thinking that the NRC should take counterfeit part allegations more seriously.
For starters, the NRC might want to re-read the story about United Airlines Flight 232.