Who Destroyed Three Mile Island? - Nickolas Means | The Lead Developer Austin 2018
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Published 2018-03-21
Why?
When something bad happens, it’s easy to just blame someone and move on. Taking the time to find the systemic causes, though, will not only help keep the problem from repeating, it will enable you to build the psychological safety necessary for your team to truly collaborate. Let’s let the story of Three Mile Island teach us how to make our teams stronger through systems thinking and just culture.
All Comments (21)
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Came in for a nuclear dissaster story and came out with a life and management lesson. DAMN YOU NICKOLAAAAAAAAAS
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Came to the video interested in nuclear accidents, left it with a new way of looking at mistakes. Awesome talk!
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Another problem was that although the same valve had gotten stuck 18 months earlier at another reactor of the same design, resulting in the same problem (but discovered by the operators in time) Babcock & Wilcox had failed to notify other users of this reactor design of the flaw.
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Comrade Legasov sent me here.
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Reminds me of the Challenger disaster. The O-rings were never supposed to leak as failure could result in the loss of the spacecraft, but since the spacecraft managed to survive (somehow) multiple launches, leaks were ignored, until a particularly cold day arrived. A culture of deviance set in. Likewise, at TMI the valve wasn't supposed to leak but was ignored because things continued to run even though the water temp exceeded 200 degrees. If the valve problem had been addressed at the start, the reactor wouldn't have been subsequently lost.
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This has been the most amazing explanation of 3 Mile Island I have heard to date. Thank you for this!!!
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As a human factors facilitator and Error Occurrence investigator within the aviation sector I found this to be the best explanation of both human and environmental factors contributing to an accident. Indeed we have come a long way with a no blame culture and a positive attitude towards open reporting. Excellent presentation thank you.
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A LITTLE KNOWN TMI STORY: My father was one of the B&W Engineers on the first (and subsequent) conference phone calls. Unlike today these were a big deal, relatively expensive and it took some time to setup. On the first conference call an AT&T operator breaks into the call and asks, "Who's paying for this call?". Everyone at the table in three locations looks at each other dumbfounded and there is absolute silence. When there is no response the operator hangs up disconnecting the conference call. And in three places all there is to hear is the hum of the dialtone. My father was one of the B&W engineers who knew immediately what the problem was. . . albeit too late. What the current generations born after TMI need to know is that this was the END of nuclear power in the US. Old plants continue to run but many new plants under construction at the time (some actually complete) were abandoned and no new plants were approved since that time. Nuclear power has many problems (such as waste transportation and disposal), that have not been solved technically OR politically. The technical is always possible, but the political?
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My husband a former seasoned plant operator says " fear causes mistakes that otherwise be avoided " " as long as critical decision making is made under dire circumstances you can be sure mistakes will assuredly be made "
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As an electrical engineer with 45 years of experience I throughly enjoyed the story and lesson he brought to the accident investigation. It was very well thought out as was the real cause of the accident.
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Thanks for clearing that up. I've been wondering what caused it since it happened. I was a welding inspector on the Waterford 3 plant at the time and only heard rumors of incompetence which I now feel were untrue. My brother made a bundle helping to clean it up. They needed men who were knowledgeable and hadn't been exposed too much and he was a superintendent at the Fulton power plant who seldom was exposed to radiation. The men had only a very short time to work in the environment before they needed to get out. Less than ten years later my brother died of leukemia.
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Wow, wow. Thumbs up. I have never seen any nuclear "experts" explain the whole saga so clearly, let alone by an outsider.
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Superb account of both technical and human factors in this incident, but Nickolas's greatest achievement in this presentation was to make the "lessons to learn" process and the attribution of blame issue applicable to a vastly greater range of technical and human endeavours. Thank you.
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The actual length of the island is 3.4 miles. Not great, not terrible.
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Water hammer in the primary is way scarier on a sub than just "loss of propulsion and disabled [boat]." You're talking about the potential for a steam explosion in a very confined space, possibly under the surface of the ocean.
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The last 10 min was a massive eye opener for me, thank you
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Really glad to have stumbled across this excellent talk ✌️
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I am currently in charge of RCA and failure analysis in out QA department. This video is a real eye opener in dealing with people involved in a defect, and I hope others will take these lessons to heart as well.
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Very good. As a life long control systems engineer I can confirm this presentation is accurate and is in complete alignment with my own experience. TMI had a big impact not just on the nuclear industry, but industrial systems everywhere. President Carter's Commission did a fantastic job and much credit is owed to them.
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This is very timely considering the current Boeing 737 max saga, and can be applied with pilot error being story 1, and corporate cost cutting decisions being story 2.