What (not who) destroyed Three Mile Island?


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This is a rather long video (37 minutes), but it's well worth watching for several different reasons. Your understanding of the Three Mile Island disaster will almost certainly increase, as will your understanding of solid-fuel (and high-pressure) reactors in general.

But the main thing I took from this video is the idea of "first stories" and "second stories". Our first instinct is to assign blame. But as we all know, this is often unfair. In the case of TMI, blame could easily have been assigned to the operators, who made a whole series of bad moves that resulted in this disaster. But I think Nickolas Means makes a strong case that thinking in such a manner is not merely unfair, but counterproductive. He says that assigning blame is rarely (he probably means never) productive.

Based on his self-given title of "The Lead Developer", it will come as no surprise that he approaches the issue from a software developer process management perspective, which I think is interesting. But I think it must go further than that. How does this apply to our view of our fellow man? Of our brothers and sisters, nieces and nephews? Of our own children? Of our spouse?

Being LDS, I reject the "non-accountability" mindset. Being not a Democrat, I reject the rush to exculpate everyone for every boneheaded, hurtful, society- and self-destroying decision people make. I certainly disagree with the idea that a man (or woman) should never be held accountable for his/her actions and decisions that result in harm. But in an effort not to throw the baby out with the bathwater, I do think this is something worth considering deeply. What do you think?

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I agree with him.

In medicine we have a complication conference wherein we discuss what went wrong, and why it went wrong.  Occasionally the surgeon made a boneheaded decision but usually it is a honest mistake that occurred due to lack of understanding.

 

Three mile island was a classic case of screwed up information.  The reactor was not a submarine.  The feedback from the reactor was incorrect.  They allowed the unit to run with a patchwork setup.  And the alarm no workie if 60 alarms are going off at the same time!

 

As soon as you recognize that complications occur and try to recognize what went wrong, the sooner you can make better decisions and fix stupid systems.

 

 

 

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3 minutes ago, mikbone said:

I agree with him.

In medicine we have a complication conference wherein we discuss what went wrong, and why it went wrong.  Occasionally the surgeon made a boneheaded decision but usually it is a honest mistake that occurred due to lack of understanding.

 

Three mile island was a classic case of screwed up information.  The reactor was not a submarine.  The feedback from the reactor was incorrect.  They allowed the unit to run with a patchwork setup.  And the alarm no workie if 60 alarms are going off at the same time!

 

As soon as you recognize that complications occur and try to recognize what went wrong, the sooner you can make better decisions and fix stupid systems.

To the great credit of the Carter administration, the investigating committee gave a sober, clear-eyed account of what went wrong. (If you believe the video, which in this case I do. I never actually read the report.)

(Speaking of which, I did read the investigative report on the Challenger disaster, including Feynman's appendix, which was very interesting and includes him going on at some length over the engineers' apparent total misunderstanding of what they called a "safety factor. Here is video of Feynman explaining on CNN what happened in the commission investigation.)

 

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