On March 3, 2022, 10 Russian armored vehicles and two tanks approached the Zaporizhzhia Nuclear Power Plant (ZNPP) in southeast Ukraine, just a week after the Russian Federation began a formal invasion of Ukraine. The initial assault lasted through the night and eventually ceased the following day, but the military action and presence at the ZNPP had just begun. Russian troops and the Russian nuclear agency, Rosatom, began to occupy the plant and control all operations, including who is allowed to access the plant and the facilities, how the replacement equipment supply chain operated, and how safety and security measures were implemented. Reports of violence, extreme stress, and torture of Ukrainian ZNPP operators began to emerge in the months following Russian occupation, and staffing shortages have since plagued the plant’s operation. In October 2022, Russian President Vladimir Putin declared the ZNPP to be Russian federal property as part of the annexation of the four eastern regions of Ukraine, and ultimately forced Ukrainian employees of Enerhoatom, the Ukrainian nuclear agency, either to resign and leave the plant or sign contracts with Rosatom and eventually adopt Russian citizenship. These developments have dramatically cut the staffing levels at the ZNPP; the most recent International Atomic Energy Agency (IAEA) reports state that there are “4,500 staff employed by [Rosatom] at the ZNPP and 940 applications under consideration. Prior to the start of the armed conflict, there were approximately 11,500 staff working at the ZNPP.” IAEA Director General Rafael Grossi noted that the staffing situation is one of his primary concerns regarding the ZNPP, especially the “extremely stressful work environment in war conditions.”
Nuclear power plants (NPPs) are technologically complex facilities that require a large staff of operators, scientists, and security personnel deeply familiar with the intricacies of the equipment they work with. The human element of safety and security at NPPs cannot be overstated, as every nuclear reactor and facility is unique, even if it is the same make and model as other facilities. In addition to the plethora of operation manuals that operators must learn, operators must acquire years of experiential knowledge specific to the machinery they work with that is not necessarily written down in manuals or easily transferrable to other individuals. Onboarding new employees usually takes months of shadowing and studying the experienced operators. Furthermore, the development and sustainment of a healthy nuclear safety and security culture, one that rewards staff for delivering hard truths and depends on mutual trust and transparency, is critical to NPP’s safe and secure operations. Over the more than 30 years of Ukraine’s sovereign control over the plant since the end of the Soviet Union, Enerhoatom has instituted many safety, security, structural, and other scheduled maintenance upgrades to which Russia was not privy. Flooding the plant with hundreds of new employees within the span of a few months would in the best of circumstances create an enormous challenge for an NPP. The fact that the new employees are nationals of an attacking country, backed by military force, in addition, creates a hostile environment where normal onboarding, information sharing, communications, inspections, and operations can no longer be expected and the breakdown in safety and security culture increases the risk of a security incident or safety accident occurring.
Rigorous national and international legal measures and policies that regulate the actions of nuclear facility staff can mitigate the risk of human error causing an accident. However, these measures assume that a workplace is appropriately staffed and that the employees are not operating under duress or in a conflict zone. Even in the best of nuclear facilities, human error often contributes to or is the cause of accidents or incidents and is well-documented in subsequent analysis of such events. In many cases, human error is combined with machine failure, as is the case with the 1986 Chernobyl accident and the 1979 Three Mile Island accident. While some accidents, such as the 1969 Lucens accident, are mostly due to inevitable machine failure, accidents or incidents due to explicit human error remain a very real threat, even in fully staffed facilities. The 2002 Davis-Besse NPP reactor hole was a result of inadequate inspections and untruthful reports, and the 2005 THORP internal leak was the result of a complacent security culture. A 2009 U.S. Department of Energy handbook includes a brief analysis of human error in nuclear facility accidents and incidents (referred to as “events”): “An analysis of significant events in the commercial nuclear power industry between 1995 and 1999 indicated that three of every four events were attributed to human error, as reported by [the Institute of Nuclear Power Operations]. Additionally, a Nuclear Regulatory Commission review of events in which fuel was damaged while in the reactor showed that human error was a common factor in 21 of 26 (81 percent) events. The report emphasized that ‘the risk is in the people—the way they are trained, their level of professionalism and performance, and the way they are managed.’”
Recurring power disruptions and blackouts that threaten the reactor core’s cooling equipment, falling water levels in the Kakhovka reservoir that threaten the cooling process, and nearby fighting and artillery shelling that threaten the integrity of the plant and its workers are all continuing risks to the safety and security of the ZNPP. Even if the multitude of exterior and technical obstacles were overcome, two human obstacles still stand: the lack of operators and the lack of operator knowledge. In this state of stress, confusion, conflict, and even violence, individuals will make mistakes, overlook issues, and contribute to dangerous situations. After returning from his most recent visit to the ZNPP, Director General Grossi stated that the plant has been “operating on significantly reduced staff, who are under unprecedented psychological pressure – which despite the reactors being shutdown is not sustainable.”
The six reactors at the ZNPP are currently in shutdown mode—five remain in cold shutdown, while unit 4 is operating in hot shutdown to provide the electricity needed to maintain the cooling process at the plant, as well as to supply the nearby town, Enerhodar, with power. The reactors have cooled to a point that it would take days to weeks for them to begin to meltdown and release radionuclides if there were an accident at the plant. Issues at the ZNPP have already begun to appear, as the IAEA noted spills, leaks, and equipment failures in recent reports. Additionally, the IAEA reported that it did not receive a maintenance schedule for 2024, a development that raises multiple red flags: not enough staff that can dedicate time to crucial managerial tasks and forward planning, lack of institutional knowledge, and/or lack of detailed maintenance history. Despite this, Russia continues to report that the ZNPP is “staffed with the necessary personnel to ensure the safe operation of the station.” Whether Russia and Rosatom are willing or able to return the ZNPP to its previous staffing levels is unknown, but if the past two years are any guide, it is likely that safety and security at the plant will continue to be a victim of the broader conflict.
The Enduring Risk of Human Error at the Zaporizhzhia Nuclear Power Plant
By Annie Trentham • Christina McAllister
Nonproliferation
The Zaporizhzhia Nuclear Power Plant continues to face a dire staffing crisis amidst the Russian invasion and occupation that began two years ago. With a drastic reduction in experienced operators and a hostile environment hindering normal operations, the risk of human error looms large over daily operations.
On March 3, 2022, 10 Russian armored vehicles and two tanks approached the Zaporizhzhia Nuclear Power Plant (ZNPP) in southeast Ukraine, just a week after the Russian Federation began a formal invasion of Ukraine. The initial assault lasted through the night and eventually ceased the following day, but the military action and presence at the ZNPP had just begun. Russian troops and the Russian nuclear agency, Rosatom, began to occupy the plant and control all operations, including who is allowed to access the plant and the facilities, how the replacement equipment supply chain operated, and how safety and security measures were implemented. Reports of violence, extreme stress, and torture of Ukrainian ZNPP operators began to emerge in the months following Russian occupation, and staffing shortages have since plagued the plant’s operation. In October 2022, Russian President Vladimir Putin declared the ZNPP to be Russian federal property as part of the annexation of the four eastern regions of Ukraine, and ultimately forced Ukrainian employees of Enerhoatom, the Ukrainian nuclear agency, either to resign and leave the plant or sign contracts with Rosatom and eventually adopt Russian citizenship. These developments have dramatically cut the staffing levels at the ZNPP; the most recent International Atomic Energy Agency (IAEA) reports state that there are “4,500 staff employed by [Rosatom] at the ZNPP and 940 applications under consideration. Prior to the start of the armed conflict, there were approximately 11,500 staff working at the ZNPP.” IAEA Director General Rafael Grossi noted that the staffing situation is one of his primary concerns regarding the ZNPP, especially the “extremely stressful work environment in war conditions.”
Nuclear power plants (NPPs) are technologically complex facilities that require a large staff of operators, scientists, and security personnel deeply familiar with the intricacies of the equipment they work with. The human element of safety and security at NPPs cannot be overstated, as every nuclear reactor and facility is unique, even if it is the same make and model as other facilities. In addition to the plethora of operation manuals that operators must learn, operators must acquire years of experiential knowledge specific to the machinery they work with that is not necessarily written down in manuals or easily transferrable to other individuals. Onboarding new employees usually takes months of shadowing and studying the experienced operators. Furthermore, the development and sustainment of a healthy nuclear safety and security culture, one that rewards staff for delivering hard truths and depends on mutual trust and transparency, is critical to NPP’s safe and secure operations. Over the more than 30 years of Ukraine’s sovereign control over the plant since the end of the Soviet Union, Enerhoatom has instituted many safety, security, structural, and other scheduled maintenance upgrades to which Russia was not privy. Flooding the plant with hundreds of new employees within the span of a few months would in the best of circumstances create an enormous challenge for an NPP. The fact that the new employees are nationals of an attacking country, backed by military force, in addition, creates a hostile environment where normal onboarding, information sharing, communications, inspections, and operations can no longer be expected and the breakdown in safety and security culture increases the risk of a security incident or safety accident occurring.
Rigorous national and international legal measures and policies that regulate the actions of nuclear facility staff can mitigate the risk of human error causing an accident. However, these measures assume that a workplace is appropriately staffed and that the employees are not operating under duress or in a conflict zone. Even in the best of nuclear facilities, human error often contributes to or is the cause of accidents or incidents and is well-documented in subsequent analysis of such events. In many cases, human error is combined with machine failure, as is the case with the 1986 Chernobyl accident and the 1979 Three Mile Island accident. While some accidents, such as the 1969 Lucens accident, are mostly due to inevitable machine failure, accidents or incidents due to explicit human error remain a very real threat, even in fully staffed facilities. The 2002 Davis-Besse NPP reactor hole was a result of inadequate inspections and untruthful reports, and the 2005 THORP internal leak was the result of a complacent security culture. A 2009 U.S. Department of Energy handbook includes a brief analysis of human error in nuclear facility accidents and incidents (referred to as “events”): “An analysis of significant events in the commercial nuclear power industry between 1995 and 1999 indicated that three of every four events were attributed to human error, as reported by [the Institute of Nuclear Power Operations]. Additionally, a Nuclear Regulatory Commission review of events in which fuel was damaged while in the reactor showed that human error was a common factor in 21 of 26 (81 percent) events. The report emphasized that ‘the risk is in the people—the way they are trained, their level of professionalism and performance, and the way they are managed.’”
Recurring power disruptions and blackouts that threaten the reactor core’s cooling equipment, falling water levels in the Kakhovka reservoir that threaten the cooling process, and nearby fighting and artillery shelling that threaten the integrity of the plant and its workers are all continuing risks to the safety and security of the ZNPP. Even if the multitude of exterior and technical obstacles were overcome, two human obstacles still stand: the lack of operators and the lack of operator knowledge. In this state of stress, confusion, conflict, and even violence, individuals will make mistakes, overlook issues, and contribute to dangerous situations. After returning from his most recent visit to the ZNPP, Director General Grossi stated that the plant has been “operating on significantly reduced staff, who are under unprecedented psychological pressure – which despite the reactors being shutdown is not sustainable.”
The six reactors at the ZNPP are currently in shutdown mode—five remain in cold shutdown, while unit 4 is operating in hot shutdown to provide the electricity needed to maintain the cooling process at the plant, as well as to supply the nearby town, Enerhodar, with power. The reactors have cooled to a point that it would take days to weeks for them to begin to meltdown and release radionuclides if there were an accident at the plant. Issues at the ZNPP have already begun to appear, as the IAEA noted spills, leaks, and equipment failures in recent reports. Additionally, the IAEA reported that it did not receive a maintenance schedule for 2024, a development that raises multiple red flags: not enough staff that can dedicate time to crucial managerial tasks and forward planning, lack of institutional knowledge, and/or lack of detailed maintenance history. Despite this, Russia continues to report that the ZNPP is “staffed with the necessary personnel to ensure the safe operation of the station.” Whether Russia and Rosatom are willing or able to return the ZNPP to its previous staffing levels is unknown, but if the past two years are any guide, it is likely that safety and security at the plant will continue to be a victim of the broader conflict.
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