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目次

Preface ix Acknowledgments xxi Reading Notes xxv CHAPTER ONE:Complexities in Control 1 The Limits of Regulation and Self-Regulation 5The Tradeoff Quandary 9 Concerns, Commitments, and Control 17 The NuclearConnection: Naval and Corporate Orders 23 The Cycle of Self-Improvement: TheEvent Review System 28 CHAPTER TWO: Arrow Station: A Leaking Valve inContainment 35 An Account of a Valve Repair Effort 35 Event Inquiries44 The Teams' Reports 48 Insights and Excursions 59 The Parts Template 88CHAPTER THREE: Bowie Station: A Reactor Trip and a Security Lapse 98An Account of an Automatic Reactor/Turbine Trip 98 Trip Event Review TeamReport 100 Insights and Excursions 103 An Account of a Security Lapse 120Mis-Authorization Event Review Team's Report 123 Insights and Excursions 125The Two Events: Tangential or Essential? 142 CHAPTER FOUR: CharlesStation: Transformer Trouble 144 An Account of a "Significant Near-Miss"on a Generator Step-up Transformer 144 Witnessing "A New Find" 151 TeamReports 154 The Reception of the "Organizational Effectiveness" Team Report158 Insights and Excursions 162 CHAPTER FIVE: Logics of Control 196Three Logics of Control Culture 198 An Infrastructure of Conundrums 203Control in Real Time 209 Doubt, Discovery, and Interpretation 213 Words,Meanings, and Deeds 217 Standing in the Way: A System of Claims 224Crystallizing the Difference: Numbers and Values 230 Objective andSubjective, Technical and Substantive 235 Certainty and Ambiguity, Doubt andDiscovery 237 CHAPTER SIX: Intellectual Capital for Regulation andSelf-Regulation 240 Controlling and Coordinating Knowledge 242 TheScope of Event Reviews 248 "Maintenance Is Going to Save You" 257 "Levelsof Maturity" 262 Re-Imagining the Culture of Control in the Nuclear PowerIndustry 266 From Functions to Meanings: A Second Axis for Risk-Reduction270 Into the Next Half-Century 276 APPENDIX ONE: Senior ManagementGroup at Overton Station 283 APPENDIX TWO: Nuclear Power Plant Modes ofOperation or Shutdown 286 APPENDIX THREE: Study Description 288 Notes289 Bibliography 325 Index 367