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Who Destroyed Three Mile Island? - Nickolas Means | The Lead Developer Austin 2018 

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On March 28, 1979, at exactly 4 o’clock in the morning, control rods slammed into the reactor core of Three Mile Island Unit #2, halting the nuclear reaction because of a fault in the reactor cooling system. At 4:02, the automated emergency cooling system activated as the reactor core temperature continued to rise. At 4:04, one of the plant operators made the befuddling decision to switch off the emergency cooling system, dooming the reactor to partial meltdown.
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.

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24 сен 2024

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Комментарии : 1,6 тыс.   
@eFeXuy
@eFeXuy 5 лет назад
Came in for a nuclear dissaster story and came out with a life and management lesson. DAMN YOU NICKOLAAAAAAAAAS
@rizkiadrianhakim
@rizkiadrianhakim 5 лет назад
exactly lol
@bryankirk3567
@bryankirk3567 5 лет назад
who is nicholassssss
@Kharnellius
@Kharnellius 5 лет назад
@@bryankirk3567 He said Nickolaaaaaaaaas. ;)
@ToreDL87
@ToreDL87 5 лет назад
If you need videos to show you how to live you'll be DEAD if internet and tv goes dark.
@MBooley
@MBooley 5 лет назад
Legit
@Swarm509
@Swarm509 5 лет назад
Came to the video interested in nuclear accidents, left it with a new way of looking at mistakes. Awesome talk!
@folterknecht1768
@folterknecht1768 5 лет назад
Yes and no ... Problem is, that those 4 guys who operated the reactor were basically competent, they just were stuck in their submarines and the reactor design left something to be desired (especially monitoring) as already said in the video. Now often enough you are dealing with incompetent or downright stupid people. Imo it's not as clean cut as the presenter wants to make you believe at the end of the video.
@grunt7684
@grunt7684 5 лет назад
@@folterknecht1768 Yes, this design has heat exchanger redundancy but not coolant pump redundancy. WTF.
@Swarm509
@Swarm509 5 лет назад
​@@folterknecht1768 This is true, and I would agree that this method works best with competent employees. I need to read the book mentioned in the video but I can see ways of using the methods discussed in the video to make sure there was no underling issues that can cause issues in the future, especially if the incompetency comes from a company culture or training issues. After this fire the people who are stupid or are grossly incompetent and which these underlying issues would not explain the mistake made.
@DaleTyler-rq3cr
@DaleTyler-rq3cr 5 лет назад
Folterknecht You are completely stuck in the blame paradigm which as everyone except you knows gets you exactly nowhere. Didn’t you learn anything from the presentation? Watch it again and you might actually discover a better model for understanding and not repeating complex technical/human systems failures than the blame game of calling it human error or in your comment, incompetence. Dalepsych
@_aullik
@_aullik 5 лет назад
​@@DaleTyler-rq3cr Not really. If you watch the talk the base assumption is that those people tried their very best to stop the accident. However this is not always the case. If you have people that are just 'working for the paycheck' your systematic problem lies in your hiring process and while you should fix this you also have to blame the workers that you either have to "fix" or replace
@anvilfireguru8690
@anvilfireguru8690 5 лет назад
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?
@Thumbsupurbum
@Thumbsupurbum 5 лет назад
One such completed plant is the one I live near. Shearon Harris Nuclear Power Plant, in NC. I believe it was the last new reactor to go online in the US, in May of 1987. But getting a hold of new parts must be getting difficult with the ban, because they've had to refurbish and install the turbine from TMI Unit 2.
@jfbeam
@jfbeam 5 лет назад
"Being built" is not "operating". We've (partially) built many new plants over the last 30 years. As far as I know, none of them have ever been licensed and turned on. (Cherokee, SC was never finished - sold to E.O..Studios and he filmed the Abyss in the flooded reactor building. They started building a new site near there several years ago; I doubt that one will ever produce power.)
@jtc1947
@jtc1947 5 лет назад
Can't say to the rest of Your story but the DEAL ABOUT the AT&T operator is on par with some stuff that happened at my place of employment years ago. One of the VICE PRESIDENTS had a call that involved a Spanish speaking caller. A stupid operator cancelled the call because She was NOT BI-LINGUAL . The officer at our company called a supervisor to rip them a new one and who ever He spoke with thought that he was talking about bi-sexual instead of BI-LINGUAL and got all offended. There was another deal where The company lost BIG MONEY because Something went wrong in the AT&T phone system.One of my Supervisors was ready to bite nails in two!
@denzilhoff6026
@denzilhoff6026 5 лет назад
Watts Barr unit 1 came online in 1996. Admittedly the license was approved in 1973. Unit 2 went critical for the first time in 2016.
@gennadiyleyfman6920
@gennadiyleyfman6920 5 лет назад
What about a new nuclear plant in Georgia, which is supposed to become operational in a near future? Or is it?
@kirstenspencer3630
@kirstenspencer3630 Год назад
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 "
@Carstuff111
@Carstuff111 5 лет назад
This has been the most amazing explanation of 3 Mile Island I have heard to date. Thank you for this!!!
@macgto
@macgto 5 лет назад
I live and work in the shadow of this plant, and I can tell you, that as neighbors of Three Mile Island, we have never, in 40 years, been give such a clear and detailed accounting of what happened inside that plant.
@Carstuff111
@Carstuff111 5 лет назад
@@macgto It is one of those thing where, if things can be hidden, things will be hidden, and we (the general public) will never really know what goes on with things like this in full. While this video is by far the best explanation of what happened I have seen to date, I still think we will never know the full truth.
@macgto
@macgto 5 лет назад
I'm sure you are correct. My father is a retired engineer who worked at the Calvert Cliffs Nuclear Plant in Maryland, I forwarded this video to him to watch. I'm interested on hearing his take.
@250txc
@250txc 5 лет назад
Car, you may not have noticed this, but normally it takes decades on most any high-level screw-up like this before the ~truth will come out,,, Usually most or all the people in question are dead,,
@spvillano
@spvillano 4 года назад
@@macgto howdy, neighbor! I rather miss seeing the plume from the remaining unit, but alas, its cost was double natural gas electrical production. The major part of the entire hot mess was human factors engineering. Seriously, whoinhell looks on the far side of their console for a critical indicator? I'll not go into ignoring a submarine reactor SCRAM decay heat being trivial, it's close to a stick of TNT going off, nobody in their right mind ignores that! Per scale, both were equally important, the sub having a lot simpler number of systems. And of course, more technical geared indicators, of every part of the operational components of the system, some Rickover SOB insisting on them, as well as precise engineering documentation and methods for nuclear submarines.
@markcowell7257
@markcowell7257 5 лет назад
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.
@DaleTyler-rq3cr
@DaleTyler-rq3cr 5 лет назад
Mark Cowell. Well said. I heartily concur with all you have written. I, too, really enjoyed the clear development of both technical and human factors. The most important ‘take-away’ for me was the importance of creating a blame-free environment in trying to understand complex interactive systems failures of all sorts. For without a clear and accurate time-line, we can never learn from the past or devise corrective measures for future improvements. Mistakes are for learning, apportioning of blame gets us nowhere. I remember stressing the benefits of making mistakes in the educational process to my children, recasting mistakes as good rather than shameful as long as one learnt something from each one and didn’t keep repeating the same error. I will be trying to locate more of his lectures as I found this one so enjoyable. A most articulate and informative speaker. Dalepsych
@CrotalusHH
@CrotalusHH Год назад
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.
@DavidWilliams-on9bu
@DavidWilliams-on9bu Год назад
he's an idiot. I am a Nuclear Power Plant Operator and Engineer. These Condensate Polishers are on the secondary side of the Reactor Plant...and not on the Primary Side within the Reactor Plant Shielded Compartment (room)...where the Reactor Core, Primary Pumps, Pressurization Systems, and the Electro Mechanical Control systems that either raise or lower the Hafnium Controls are. If it is on the secondary side; then it cannot cause a "core meltdown". He even says that "one of the engineer looked into the viewing port of No. 7 polisher". You cannot look into something that is inside the Primary Reactor System...unless the Primary is completely shut down for many hours or days. They will not run the risk. There are 7 Polishers and they operate independently...not in series. This means that you can shut down one...and still keep the plant operational. This is called "double and triple back-up redundancy" ... and it exist in EVERY POWER PLANT. These Polishers remove any possible contaminates on the "Steam Side" of the Secondary Steam Generator Systems. They are not actually "necessary" to operate a plant. They are a overly redundant "cleaning system". You can read about them here....en.wikipedia.org/wiki/Condensate_polisher A condensate polisher is a device used to filter water condensed from steam as part of the steam cycle, for example in a conventional or nuclear power plant (powdered resin or deep bed system). It is frequently filled with polymer resins which are used to remove or exchange ions such that the purity of the condensate is maintained at or near that of distilled water. There is ZERO STEAM IN THE PRIMARY SYSTEM. This does not matter if it is a conventional or nuclear powered system. IN other words...there is no "condensate" on the primary side; because this is where the heat is generated and the water inside all components and piping...MUST REMAIN WATER ALWAYS. This is true in a conventional plant. A Steam Generator has U-tubes on the inside that carry hot water "internally"...which heat the pipes to ~600 degrees. The outside of the pipes are surrounding by water at ambient temperatures...usually 80 degrees; depending on the water source. The water "flashes" to steam due to temperature differential and "rises" to the top of the steam generator; where the piping directs this steam to a turbine; which spins an AC/DC motor generator that "creates Electricity". The AC motor generator is connected to the Transmission lines that distribute power to "where you want it". Condensate is the very last thing to happen to the steam....has it cools down stream of the Turbines that the steam moves and therefore...CANNOT AFFECT THE PRIMARY REACTOR CORE...in anyway; whatsoever. If the "steam generator relief valve" were to lift...the Reactor core would have already scrammed...and the control rods would have gone into place. Therefore, since the entire system's "Fission Heat Reaction" would have been stopped in 2 seconds; then there is NO EXCESSIVE HEAT. As a matter of fact...the Polishing system can be completely bypassed and you can dump regular city water into the Steam Generator to "cool down the system". There would have been no reason to "lift the steam generator Steam Relief Valves". He says that "the system stopped pumping water into the Secondary Steam Generator side of the Secondary system. Well; if this is true....NO WATER MEANS NO STEAM....which means that the Steam Relief Valves would have released NO STEAM into the atmosphere. And, unless you have an "over pressure situation" in the Steam Generator; you can continue to spin the turbines with the residual steam...as the Reactor Core continues to Cool Off...due to the SCRAM EVENT; where ALL FISSION and ALL HEAT GENERATION STOPS. So...this entire "official" narrative is a bunch of propagandized bullshit...and the NOVICE on the video; whose dad gave him a book on "how things work"....does not know what he's talking about or how a Power Plant...nuclear or otherwise....actually work. He has ZERO business talking about things; when does not know...HOW IT WORKS in the Real World of Power Generation and/or Power Distribution.
@timgernold1715
@timgernold1715 Год назад
Can verify that in Navy Nuke world having the pressurizer go solid is considered one of the most dangerous things you can do to a shipboard plant. It's drilled in our heads from day 1 and is brought up in every test, every qualification.
@plateoshrimp9685
@plateoshrimp9685 5 лет назад
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.
@UncleKennysPlace
@UncleKennysPlace 5 лет назад
That's the issue with complex systems: you can't scream about every little problem until it becomes a trend.
@plateoshrimp9685
@plateoshrimp9685 5 лет назад
@@UncleKennysPlace I would think that we might want to scale our level of caution with the size of the repercussions. Don't we determine whether a problem is big or little by the size of the potential consequences?
@richardtwyning
@richardtwyning 5 лет назад
Secrecy caused this accident, just like it did with Chernobyl!
@starcitizen890j5
@starcitizen890j5 5 лет назад
Sounds like Boeing 737max sticking angle of attack sensors. Not to mention the fact it only used one sensor not both. Plus the simulator felt nothing like a real trim level take over by the computer.
@chip8874
@chip8874 5 лет назад
@@plateoshrimp9685 sounds like outcome bias. Kenny's point stands because every little problem could be a big problem in a reactor. We just don't know how things will play out. The speaker even made a joke about the trivial "elevator stuck" alarm. Well if those men had been stuck in the control room because the elevator was stuck, we would all be sitting here complaining about how obvious it is that the elevators are so important because elevators get people out of a dangerous area quickly.
@philipwilkie3239
@philipwilkie3239 5 лет назад
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.
@noblackthunder
@noblackthunder 5 лет назад
i think accident like these are important ... We are lucky we had so few .. and only one has been a real big catastrophe .... I rather have an accident like that then chernobal happening again ... I would almost say accident like that are the best thing that can happen ... we can learn from them and make sure that with nuclear power the world is not just a greener space switching out dirty coal power ... but make sure that nuclear is as save as possible by learning from mistakes ... We learn from mistakes ... and when a mistake happens without major consequences ... then this is a good thing ... Sure in the end it was en expensive mistake .... but a good one. Mistake is maybe the wrong word ... but i cant find a better word ... maybe accident ... but i kinda feel accident is kinda wrong too to use ... Anyway .. with only 3 major accidents ... where this one here was not really that bad in the end .... nuclear power seems to be still a save power source .. and we can learn from japans latest accident too and make nuclear even safer
@krashd
@krashd 5 лет назад
@@noblackthunder The problem is that now we are on the cusp of having perfectly safe reactors the damage is already done and getting new plants commissioned is a nightmare. Not to mention the folks who overestimate the danger and magnitude of nuclear waste by peddling the myth that it's everywhere and can never be processed. The west should educate people to the truth about nuclear like they do in Korea and Japan but big oil lobby against it. Fukushima happened in Japan and the Japanese are still pro-nuclear, they are a very clever people with a low level of ignorance. I hope North America and Western Europe become like that some day.
@noblackthunder
@noblackthunder 5 лет назад
@@krashd yea fake news about nuclear power is just sad... on one side we want green energi, on the other side people dont want nuclear... meaning we have no power source that can meet the demands... its inpossible without nuclear. We have learned so much from the 3 dissasters...
@martingrundy5475
@martingrundy5475 5 лет назад
No Fred. We will eventually go to even bigger monoliths of human ingenuity. Fusion is actually really likely within the thirty years often joked about. There have been some remarkable breakthroughs over the last five years. There is now a massive international collaboration to build the biggest yet Tokamak type device called ITER, that may be the first actual step in producing more energy than the process consumes. Though this still will be a test device for determining how better to proceed from here. Suggesting Batteries is the answer simply illustrates how clueless you are regarding the actual realities and engineering problems. You seem to be mixing up scales somewhat. To imagine batteries and solar, wind, and tidal is the answer is preposterous. I think you need to actually go and check out how much energy we are talking about JUST in the USA. Let alone the planet. With all the cells needed for the future electric vehicle revolution that is definitely coming, we are going to have to manufacture some tidy number of Lithium Ion cells. Or someone come up with another entirely new storage medium. We can't have high level reservoirs everywhere now can we?
@fazole
@fazole 5 лет назад
@@krashd But Japan is also a very conformist and high trust society which leads them to be overly trusting or deferring to authority.
@markwheeler202
@markwheeler202 5 лет назад
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.
@garyhoffmann1615
@garyhoffmann1615 5 лет назад
"multiple lunches" so it indigestion?
@markwheeler202
@markwheeler202 5 лет назад
@@garyhoffmann1615 Over weight
@fredgarvin9493
@fredgarvin9493 5 лет назад
As far as the challenger goes, if they would have noticed the fire coming out of the side of the booster rocket, the boosters could have been jettisoned early to save the challenger.
@markwheeler202
@markwheeler202 5 лет назад
@@fredgarvin9493 Assuming Challenger would have survived the jettison of the SRB's operating at full power (questionable), it would still have to gain enough altitude with its main engines to reach the Azores for a safe landing, else it would have made one giant splashdown in the Atlantic.
@이용현-z3j
@이용현-z3j 3 года назад
Fineman has discovered the cause of a spaceshuttle which id is the deformation of a o riing. he is a excellent genius even if doesn't work at the Nasa. 🌻
@justcarcrazy
@justcarcrazy 5 лет назад
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.
@akjackson009
@akjackson009 2 года назад
5-why
@barryklinedinst6233
@barryklinedinst6233 5 месяцев назад
What happened to RCA? My family had a business in York Pa. We did very well selling their TVs. They made some great products . I'm curious because they were big in our area . We bought them from D&H distributors in Camp Hill PA. They sold to 100 dealers and we sold more top end than anyone. I miss their flat screen 27 and 31 inch.
@johncgibson4720
@johncgibson4720 5 лет назад
Wow, wow. Thumbs up. I have never seen any nuclear "experts" explain the whole saga so clearly, let alone by an outsider.
@nawdawg4300
@nawdawg4300 5 лет назад
Seriously. I've been on a Nuclear Reactor Accident binge, and just watch an hour-long doc about TMI. The first 20 mins of this video already had way more information than that whole documentary.
@Pow3llMorgan
@Pow3llMorgan 5 лет назад
Sometimes you want someone who's an expert in storytelling, rather than an expert in the field which the story is about.
@denzilhoff6026
@denzilhoff6026 5 лет назад
He got the event 95% right. He skipped items that wouldn't add to your understanding but an engineer would have spent time going over. Trust me, I worked the industry for 20 years. They don't skip anything.
@minnesota7010
@minnesota7010 5 лет назад
@@nawdawg4300 I came here from HBO🤔 I've been on a 5 day binge 🤪🤪.
@xuerian
@xuerian 5 лет назад
@@minnesota7010 RU-vid: Hey kid, I've got some more of that _Nuclear Reactor_
@billietyree6139
@billietyree6139 5 лет назад
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.
@piotrd.4850
@piotrd.4850 2 года назад
My condolences and thanks to you and your brother.
@kumoyuki
@kumoyuki 5 лет назад
Arguably one of the most important videos I've seen in a long time. Studying engineering failures is like that. And then there's the important character lessons for organizations...
@jonnytightlips513
@jonnytightlips513 2 года назад
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.
@oidpolar6302
@oidpolar6302 Год назад
It's not a human factor, it's a greedy factor
@rfvtgbzhn
@rfvtgbzhn Год назад
Still pilots and other people working in aviation are often fired and sometimes charged and imprisoned if they make grave errors. And I think this is a good thing, as not all people care about other people, so some people only avoid errors if they have consequences for themselves. This is especially important for ATC: if a pilot causes a severe incident he might get killed himself, if an ATC operator causes it, he will be physically unharmed.
@grumpy3543
@grumpy3543 3 дня назад
@@rfvtgbzhn not true. If the mistake was not intentional then they don’t prosecute the pilots. They could remove him from flying duties and retrain him if there’s a deficiency. Or more likely they will look at training and procedures to see where the problem lies. Remember that accidents have a long chain of events that have to line up for it to occur. Break any link in that chain and you will mitigate that accident. And that’s where the Swiss cheese effect comes in. It’s like slices of Swiss cheese. When all the holes line up the problem gets through. We can add layers of Swiss cheese and hope that the mistake will be trapped. That’s how aviation has become so safe in the last 50 years. And that’s why new reactors will be nothing like three mile island design.
@rfvtgbzhn
@rfvtgbzhn 2 дня назад
@@grumpy3543 negligence is punishable.
@grumpy3543
@grumpy3543 День назад
@@rfvtgbzhn True. But willfully disregard for safety is a jail able offense. Negligence could be too. But the regulations don’t read that way. Now were these guys at three mile island negligent? It doesn’t say that. They were using their Navy training from submarines. But that didn’t cross over to this giant reactor. This will never happen again because we learned so much. Same with all the aviation accidents from the past. That’s why procedures and aircraft design are light years ahead of where they were even as recently as the 80’s.
@markotik75
@markotik75 5 лет назад
Really glad to have stumbled across this excellent talk ✌️
@darthkek1953
@darthkek1953 5 лет назад
The actual length of the island is 3.4 miles. Not great, not terrible.
@Markstrosity
@Markstrosity Год назад
Took me three years to get the joke.
@darthkek1953
@darthkek1953 Год назад
@@Markstrosity 3.4 years actually. Not great, not terrible.
@GavinScrimgeour
@GavinScrimgeour 11 месяцев назад
@@darthkek1953😂 👏🏻
@FS2K4Pilot
@FS2K4Pilot 5 месяцев назад
😉
@dennisberg2474
@dennisberg2474 5 лет назад
The last 10 min was a massive eye opener for me, thank you
@thomaspayne6866
@thomaspayne6866 5 лет назад
No, he’s wrong. 1) killing someone in a car crash because you made a misjudgment is fine and doesn’t require punishment 2) but killing someone in a car crash because you were texting is not fine and does require punishment People need to 1) tell the truth regardless 2) be responsible 3) accept responsibility 4) have fear of punishment as a motivation to do your best. We generally don’t punish people for making honest mistakes. If there is a punishment, there’s usually is reward of less punishment for being upfront and honest and that’s because they accept responsibility. Tell the truth always regardless of the outcome, and do not take a knee to amorality or immorality to prevent lying. If a person lies about the 3 mile disaster to save himself, then he’s not taking responsibility of himself and the lives of others. Tell the truth always.
@TheJuggtron
@TheJuggtron 5 лет назад
@@thomaspayne6866 imagine confusing systemic design problems with negligence. The talk conflates neither, you are spreading misinformation - either intentionally as a bad actor or to be an edgy contrarian. Either way your comprehension is terrible if that is what you take away from this.
@jskratnyarlathotep8411
@jskratnyarlathotep8411 5 лет назад
@@thomaspayne6866 it turns out you simply can not demand from people to tell the truth despite they know they'll be punished based on what they're saying. It just does not work that way. You can ask, you can order, but the most of them just won't comply
@thomaspayne6866
@thomaspayne6866 5 лет назад
jSkrat Nyarlathotep -- No, not for amoral and chaotic society they won’t. There’s a reason why religion exists. It instills morality, logic, truth, rules, self-restrictions from birth. When we lost our religion, or “when god has died” in our society, so does morality. And that is how we get a society full of upside down people. People who live in a world of chaos and inversion. Also known as “clown world”, or hell. Matriarchal societies live in chaos, and the men of today are becoming rapidly feminine, chaotic, amorality, demoralized, degenerate. THEY ARE LIVING IN UPSIDE DOWN WORLD.
@jskratnyarlathotep8411
@jskratnyarlathotep8411 5 лет назад
@@thomaspayne6866 we've never lived in right world, no matter how religious the society were. There always were a sins, there always was the need of mercy from god. I think it means that this is just not the way. It's just not working. It is better to accept the sinners and deal with them, than trying to convert them. All our history tells us that you can not create and maintain for long a so to say "holy" society. And I really doubt that religious "eye for the eye, blood for the blood" is better and more effective, than modern judging system. (I'm not saying ours is perfect)
@vholes2803
@vholes2803 2 года назад
I worked for some years as an IT Systems Administrator, including at a job where a number of servers had not been maintained for some time before I started. The situation bore a resemblance to the screed of error messages thrown at the TMI operators, critical, major, minor and trivial messages, where the fundamental first step was to thin out the hullabaloo to make progress. Luckily I had far more control over my situation, my deepest sympathy to the TMI operators. There are some interesting sources out there, particularly on aviation industry disasters and near-misses, talking about the design and ergonomics of instrumentation. Error reporting and "working as specified" and intermittent failures are non-trivial problems for complex systems.
@TheReaverKane
@TheReaverKane 5 лет назад
This has to be one of the best talks i've ever watched! Kudos!
@byebye1493
@byebye1493 5 лет назад
I take it you haven't come across Yuri Bezmenov's video presentations on YT?
@julianalcock1019
@julianalcock1019 4 года назад
In telecoms, we had "compelled signalling". One end sends a signal and waits for the distant end to respond. It does not assume that the other end has acted appropriately until one of a range of acceptable signals is sent back and this is in a non safety critical situation. In the case of the valve, "I told you to close" is simply not good enough. Only " I have definitely closed and here is my signal confirming that this has happened" is good enough in a safety critical environment )and it's good practice anyway).
@immikeurnot
@immikeurnot 5 лет назад
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.
@redgemon
@redgemon 4 года назад
It wouldn't be a steam explosion but could cause a leak, but that's what the reactor compartment is for 😁 But yeah "loss of propulsion" while underwater is kind of a big deal 😓 There's a chance to never come back up... Also, as a Navy "nuke" I can verify about the obsession with never "going solid". Navy reactors have lots of transient power operation, which is another difference he doesn't mention. Levels all over the sub plant could be changing by the minute or hour whereas a land plant is more steady.
@bettygreenhansen
@bettygreenhansen 4 года назад
Kursk. Just saying Exploding submarine
@timavery99
@timavery99 4 года назад
@@redgemon Pretty much, a steam leak maybe . Our Navy nukes can go from a cold start to underway in 30 minutes or less. Civilian plants... 9 months. SSBN 626 Gold and 644 Gold. US Navy has never had a nuclear accident. Multiple redundancies and the worst best training on the planet! Did these civilians have have an ORSE board?
@redgemon
@redgemon 4 года назад
@@timavery99 😮wow I was on the 626 in prototype 😅
@Nunya_Business_
@Nunya_Business_ 3 года назад
@@redgemon Or a carrier, where do you think catapult steam comes from anyway...
@cconnors
@cconnors 3 года назад
Nickolas is one of the best technical speakers I've ever encountered. It's a joy to listen to him give a talk.
@wphb66
@wphb66 5 лет назад
Wow, what an incredible video! Very educational from a nuclear standpoint (what exactly happened) but was rewarded with a management and engineering and life lesson. Thank you for this!
@gregoryhayes2823
@gregoryhayes2823 Год назад
Thank you for the excellent video. Applause 🎉. I was a senior manager of control departments in large coal fired power plants for a 35 year career. That meant every blip in the power plant usually came my team's way for solution. I have seen operators admit to fault that I absolutely knew was not their fault but upper plant management being compliant with having the root cause and a solution nearly immediately available for Corporate who also often have regulator reporting requirements in mind. Some unit trips or equipment trips have causes so subtle or unexpected that the right question is readily ovelooked. Sneak circuits can lay dormant for years until an operator may need to adjust something to exactly the same setting as always but in combination with any of a thousand other settings uniquely in place at that time, drives the system unstable. Luckly those are rare occurances and redundantly designed tripping systems take over. Finding the needle in the haystack was both frustrating and rewarding and absolutely necessary. I would go on looking for the real cause long after solutions had been implemented. Nuclear power plants are highly regulated as you know. The control room layout is essentially frozen at the time of commissioning. THUS the alarm management panel layout can be a relic of regulation, leaving the control operators more vulnerable through the life of the plant.
@ManuelBTC21
@ManuelBTC21 5 лет назад
Wonderful presentation. So much to reflect on about system design, monitoring and control systems, the importance of checklists and protocols.
@peccatumDei
@peccatumDei 5 лет назад
Wow, what an excellent, EXCELLENT presentation. I have just two minor comments: First, there is another bias that can come into play, and that's normalcy bias. When things go outside our experience and training, we have difficulty recognizing the actual problem as serious. Second, I was very happy when the accident occurred, that President Carter was himself a former Navy nuclear engineer. I'm sure he asked some very pointed questions during his visit, and would have seen through any B.S.
@autohmae
@autohmae 5 лет назад
now the US has trump. His biggest bias seems to be ego.
@JasonHoningford
@JasonHoningford 5 лет назад
Carter knew his shit! ru-vid.com/video/%D0%B2%D0%B8%D0%B4%D0%B5%D0%BE--68iTvhWNB0.html
@louisefrost3676
@louisefrost3676 5 лет назад
@@JasonHoningford Yes he did and still does. Still sharp as a tack at age 94 with what is going on in our world today and often speaks out about it. An amazing man.
@Utopianx8x
@Utopianx8x 5 лет назад
Not only did I find an excellent summary on the TMI accident, I also found a new perspective for analyzing problems in the future. Thanks for the video.
@250txc
@250txc 5 лет назад
Been working at the gas station all your life? Glad you are finding out something useful,, The point he failed to bring to the forefront is, AUTOMATION,, IFF (if and only if) the software is written correctly, you can remove human-faults that screwed things up here,, -- It's really no different than automated cars driving up around,, Automation removes the human-errors that were injected into the process as shown here
@geekpower6546
@geekpower6546 5 лет назад
Comrade Legasov sent me here.
@AnjanKumarhere
@AnjanKumarhere 5 лет назад
Yes
@jimbosc
@jimbosc 5 лет назад
Did you get your 3.6 Roentgen today? Not too good....not too bad
@zoidberg444
@zoidberg444 5 лет назад
YOU DID DENT BECAUSE HES NOT THERE!
@jonmar4683
@jonmar4683 5 лет назад
you're here all because of a piece of rock?
@allocater2
@allocater2 5 лет назад
How does an RBMK reactor explode? LIES. How does a Babcock and Wilcox reactor explode? SLOW PRINTER.
@LethargicSquirrel
@LethargicSquirrel 5 лет назад
Absolutely incredible talk, Nikolas. I came to the video wondering what about TMI could be learned and used in software development (and indeed, everything else, too), and left inspired. I never really knew much about TMI, and I learned tons about that. Never really thought about "first stories" and "second stories", but that's eye-opening, too. I've heard/thought of the concept of not focusing on punishment, but rather focusing on information gathering and processing, but hadn't really ever heard of it used in a non-textbook way. Seriously good stuff here!
@samuraijack5919
@samuraijack5919 4 года назад
Thank you Nickolas. I worked at a place where chronic communication issues plagued the office and nobody ever took the time to address the underlying problems behind them. This is exactly the talk I needed to hear. It isn't about not talking responsibility and growing, it is understanding that you can try your best and still mess up. We are human and it happens.
@grayaj23
@grayaj23 5 лет назад
This is made of 100% solid awesome. I was 13 at the time, and my dad was a physicist in a completely different field, but understood enough about nuclear power to know that events like this didn't represent a problem with the safety of nuclear power. The point he kept hammering on is that taken as a whole, the system worked. No leak occurred. They experienced an unpredictable series of corner-case events and *still* did not exceed the overall inherent design safety. The series of events is one that in a conference room talking about design, someone would say "but that's absurd. Next you'll say that we have to safeguard against aliens coming in and sabotaging the system." Among other things I learned from my dad is that Murphy's Law is not simply a cynical joke about how unlucky human beings are. It is a design principle that is baked into the way a federal government should design things that must not fail. From the Apollo missions to nuclear power to the $500 hammer in the toolkit on FMC's Bradley Fighting Vehicle. It only looks like waste when someone with an agenda wants to make someone else look bad in hindsight.
@jordanrodrigues8265
@jordanrodrigues8265 5 лет назад
> corner case You should read about the Davis Besse incident. They experienced essentially the same scenario: secondary loop problem, stuck PORV, high water level in the pressurizer, manual override of the injection pumps, the primary coolant even began to boil in the pumps and reactor vessel. The only major difference in the scenario was theirs happened during startup and the core had much less decay power. Davis Besse was 18 months before Three-Mile Island. B&W didn't fully understand that their procedures and training were not preparing operators for a leak from the pressurizer, and that's the second story I take from this presentation and a little more reading. Mike Derivan was the shift supervisor at Davis Besse and has written a deeply fascinating (but more technically detailed) presentation. ansnuclearcafe.org/2014/04/23/tmi-operators-did-what-they-were-trained-to-do/ (One of the systems he mentions which was missing from this talk is the volume control system. Some water is drained from the primary loop - "letdown flow" - then cooled, filtered, demineralized. This cool water is injected at the coolant pump seals so that they don't overheat and so that the small amount of water that weeps through the seals is relatively clean. Water can also be returned to the loop through a heat-exchanger which reheats it. You can read an overview of all the systems on Gen II BWRs in the US here : www.nrc.gov/reading-rm/basic-ref/students/for-educators/04.pdf)
@ytmizz19
@ytmizz19 5 лет назад
@@jordanrodrigues8265 The pdf link from nrc.gov leads to a "page not found" error. Apparantly the NRC doesn't want us to see that info. jerks
@ytmizz19
@ytmizz19 5 лет назад
never mind, there was a right parentheses that auto. showed up after clicking the link. it works.
@Platyfurmany
@Platyfurmany 5 лет назад
When I took a Health & Safety course at work about 8 years ago, this same point was made over and over: look deeper for the true causes of an accident, which are most likely in the way a system works, or more importantly, the way a system fails. Thank you, Mr. Means, for a deeper lesson in life!
@ilovecops5499
@ilovecops5499 5 лет назад
I was one of the egghead engineers who designed the pressure vessel for the reactor. We did radiographs for every weld and each radiograph was inspected by 2 technicians at the same time
@klardfarkus3891
@klardfarkus3891 5 лет назад
Congratulations on a perfect job considering the massive stress test.
@d1agram4
@d1agram4 5 лет назад
Nice! History is preserved!
@jtc1947
@jtc1947 5 лет назад
Hi There, It seems that the pressure vessel was fine so Your team did their job and the pressure vessel was NOT THE PROBLEM . The tech error happened elsewhere in the loops. Not sure if anybody ever asked the critical question about WHAT HAPPENS if the WATER CLEAN-UP SYSTEM GOES SOUTH?
@organbuilder272
@organbuilder272 5 лет назад
Well, Since you are being so defensive, let us all tell you that this mess was NOT your fault. It was a series of bad choices made by guys who had bad information and training in the worng time and kind of reactors. The pressure vessel held as far as anyone knows. You can stop being defensive now. Relax, lean back, take a few deep breaths..... Ahhhh....... doesn't that feel much better after so many years in denial. You're cool, dude. Peace, Baby!!!.
@glennchartrand5411
@glennchartrand5411 5 лет назад
@@organbuilder272 Civilian plant owners fell into the habit of trusting the excellent training military personnel received...the problem was when the water polishers shut down and the instrumentation started giving out misleading information, the operators fell back on their military training, because thats all they had. This led to a fuel element failure. It would be akin to a police department hiring Navy Seals and saying "You guys are already highly trained , here's your gun and badge" and then being shocked when their officers engage in "reconnaissance by fire" when raiding a crack house. ("Reconnaissance by Fire" is when you shoot through doors and walls to see if anyone screams or shoots back.)
@spikey2740
@spikey2740 5 лет назад
This is an excellent description of what happened at TMI-2. Thanks for sharing. I would add only a small comment, pertaining to why steam is condensed before being pumped back to the primary loop instead of just piping it there as steam, or more likely pumping it there as steam. Typically gases do not "pump" very well, thus it takes much larger equipment to deal with the huge volumes of gases involved - certainly much, much more than it would with liquid water. When the steam is condensed back to water, the volume of materials becomes a small percentage of what would have been required as steam. So, economics and several other considerations require conversion back to something that is manageable to handle and transport. Again, thanks.
@Hypercube9
@Hypercube9 5 лет назад
My former employer had a saying "It's not the people, it's the process!" Bad design of that leaky valve, system of error lights, and a single slow-ass printer were some of the causes. If you had good design, every possibility would have been thought of in advance. Redundant systems, extra sensors and automatic processes for every contingency would have been designed and installed beforehand. Human error might have been a small factor since it was humans who designed this crappy system. And that one submarine captains advice was certainly wrong. But that's it.
@joesterling4299
@joesterling4299 5 лет назад
In the end, it's all human error. Humans designed and built the thing. I agree that it shouldn't be about blame, but about learning from our mistakes, and fixing what we did wrong going forward. There's much more to this presentation than I expected. It really needs a better title.
@10-AMPM-01
@10-AMPM-01 5 лет назад
I agree. The system wasn't designed to make it impossible for humans to screw things up. That's also the fear of AI... Automation helps, but there are so many unknown circumstances that cannot be automated. For example, the Max Air AOA probes were part of an automated system; which stalled the planes that crashed. The automatic system overpowered the operators because it's impossible to regulate all of these automatic processes without an AI or human operator. There's a learning curve for every process as well. The submariners had their learning curve; and were also never properly trained on their system.
@routtookc8064
@routtookc8064 5 лет назад
Once its automated people stop paying attention.
@Hypercube9
@Hypercube9 5 лет назад
@@routtookc8064 Well I find it hard to believe people will "stop paying attention" in a nuclear reactor, however that IS the entire point of automating something! Not that you can really pay attention to an error in the buffer of a printer that won't even be visible for another couple hours.
@gbear1005
@gbear1005 4 года назад
Why FMEA is so important. Especially a complete one where, in addition to going through ever conceivable failure mode, you also explore the inconceivable...
@BBAHUNTER
@BBAHUNTER 5 лет назад
Being one of those highly trained naval nuclear reactor operators I can tell you that this video is the best one I've seen about three Mile island. I only noticed 2 inaccuracies and numbers that were presented but the entire video is the best I have ever seen. The conclusion of it surprisingly is more important then the actual recollection of events in the story.
@donadams5503
@donadams5503 5 лет назад
OTOH Three Mile Island worked as designed failure and all. There was no crisis, the containment vessel was the bottom line solution for unkown problems and it worked. It was costly, but the design did NOT fail.
@frankthespank
@frankthespank 5 лет назад
Don Adams - It did fail, the purpose of TMI was to generate electricity and a few months after it was turned on half of it melted and never generated a single spark of electricity again. Sure, it was a safe design and Chernobyl didn’t happen but so much money and resources was put into building that plant all to just go to waste, I don’t think it’s that hard to design a safe nuclear power plant, it takes an incredibly STUPID nation with a severely flawed government (Soviet Union) to build a reactor that can blow up as spectacularly as Chernobyl did. They took a plutonium producing reactor and modified it (RMBK) to make electricity and then didn’t cover it with a containment dome and then was like “hey, let’s do some tests and see if we can blow it up”. Wow... That control room at TMI was built by idiots and that PORV should of had better indicators on if it was open or closed. I think if that plant was built today the accident would of never happened due to computers and cameras automating every aspect of TMI. TMI proved that even doing all the wrong things nuclear power can still be safe, it’s just a damn shame a new reactor was turned into a nuclear waste dump instead of generating power. That incident ruined nuclear power in America when we could be like France and had clean affordable electricity. That PWR proved to be safe but not good, I grew up next to the same reactor in Northern California called Rancho Seco, it was shut down because it had nothing but problems and the public voted to scrap it, another waste of so much potential.
@PMA65537
@PMA65537 5 лет назад
Would you believe if it's meant to generate electricity and it can't then it's failed?
@frankthespank
@frankthespank 5 лет назад
Peter Allan - I would. Such a waste of resources by dumb people. I want nuclear power to work in America, we just need smarter people in charge.
@Jablicek
@Jablicek 5 лет назад
Excellent! Blaming people is unhelpful. Finding systemic flaws and working to correct them, that's the magic.
@ffggddss
@ffggddss 5 лет назад
And this is kinda the flip side of a saying Pres. Reagan kept on his desk. It said: "It's amazing how much can be accomplished when no one cares who gets the credit." Change "accomplished" and "credit," to "fixed" and "blame," and you have the nutshell of this talk. Fred
@jolene6911
@jolene6911 5 лет назад
Amazing talk! I work in DevOps and I have already been applying some of this during outages. But there is a lot I haven’t thought of before. I am passing this around to my team because I hope it improves our incident response.
@Runoratsu
@Runoratsu 8 месяцев назад
I keep coming back to this video over and over to recommend it to people. SUCH a great talk.
@Priestonwheel
@Priestonwheel 5 лет назад
Excellent conference! Thank you! As an engineer, I appreciate a little learning like this.
@godfreypoon5148
@godfreypoon5148 5 лет назад
28:00 Well there's your problem. The reactor was being run by former reactors! They should have had qualified human operators!
@oubrioko
@oubrioko 5 лет назад
[three] _former naval nuclear reactors_ 🤔😆😉
@hindugoat2302
@hindugoat2302 5 лет назад
@@oubrioko it sounds like you are trying to blame and shame them, but its not their fault, look for the second story
@debug9424
@debug9424 5 лет назад
​@@hindugoat2302 In the talk, the presenter forgets the word "operators" at the mentioned timestamp, giving the phrase "[the 4 guys] were all former naval nuclear reactors."
@oubrioko
@oubrioko 5 лет назад
@@hindugoat2302 The: "🤔😆😉," makes it obvious that we were _poking fun_ at what the presenter _said._ As @CodeBurger explained, the narrator misspoke by calling the workers, nuclear *reactors.* _People_ are not and cannot be former nuclear *reactors.* Since you feel compelled to troll comment sections to fight against imaginary grievances which never occurred, you should at least have the common courtesy of actually _understanding_ what you read before replying impulsively. It sounds like *you* carelessly looked for the FIRST story here . . . and completely missed it.
@jimmym3352
@jimmym3352 5 лет назад
yeah reactor operators. Which were Electronics Technicians in the Navy. But usually the rating isn't used to describe their job (my rating was nuclear machinist mate but I had a further NEC classification). Presumably at least 1 of those guys was at least an officer rank who supervised Maneuvering (on surface ships we called it EOS).
@phishfearme2
@phishfearme2 4 года назад
as someone who was involved in the TMI recovery effort, I think this is an excellent summary. we all thought the operators were screwups until we looked at things from their perspective. don't blame the operators - they did what their training and experience told them to do. I think Mr Means could've talked more about "setting people up to fail" - the very design of the BW Nuclear Steam Supply System with once thru steam generators that contain very little water set operators up for failure - the PORV is designed to open with loss of condensate. the other PWR designs (Westinghouse and CE at the time) do not. BW did this to try to distinguish themselves from the other vendor (the one thrus can superheat steam slightly, others cannot) which was driven by their desire for economic success. so should we revamp capitalism also. well beyond my pay grade.
@phishfearme2
@phishfearme2 2 года назад
@Casey Riley IMPORTANT - Recognize that the PRZ is very much isolated from the Rx vessel - only being connected to the RX vessel by a small surge line that is large enough to permit pressures in the PRZ and Rx Vessel to be balanced. the question you pose is exactly the issue that the "Post TMI lessons learned" modifications addressed - the operators were trained to maintain pressurizer level (with heaters and sprays internal to the PRZ) and had no idea what the water level was in the Rx vessel (they all do now!). they were trained that if the PRZ water level is good then the Rx vessel water level is good - except when you forget about what the "P" in PWR stands for. (Note - they did not recognize the PORV was stuck open because the PORV was almost always leaking and the temp gage on the other side always indicated high temp - so a stuck open PORV did not look much different to them then during normal operations. OUCH!) ultimately
@jeffplumblee6376
@jeffplumblee6376 5 месяцев назад
​@caseyriley1014the pressurizer is supposed to be the only place in the primary coolant system that isn't completely full of liquid water. It's maintained at a higher pressure and temperature to be sure that the steam bubble remains there and only there. That's the reason pressurizer level is the proxy for vessel liquid level; the vessel is supposed to be completely full all the time, and any change in total volume of water will show as a change in pressurizer level. As the steam bubble was released through the relief valve the pressurizer pressure lowered and allowed reactor pressure to basically push the level up and a steam bubble to form in the vessel.
@ke6gwf
@ke6gwf 5 лет назад
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.
@gtpk3527
@gtpk3527 5 лет назад
That's actually just shifting blame from one group of people (pilots) to second group of people (corporate executives).
@calebdoogles
@calebdoogles 5 лет назад
I feel it'd be more appropriate to put Boeing's rushing of production, and what seems to be neglect within the process as the first story. However, the second being Boeing's own backstory of how these planes were designed, the pressures from airlines such as AA, and competitor Airbus and the latent threats that had evolved into the current scenario. It is a really interesting demonstration of this factor though! I'm in pilot training at the moment and believe this kind of mindset could be extremely critical within my future!
@joesterling4299
@joesterling4299 5 лет назад
@@gtpk3527 Yes. Though I'm impressed by the presentation, I take issue with "it's never human error." It's *always* human error. The crucial task is to identify all the human decisions and actions that led to the failure, including design and construction, and correct them going forward.
@gtpk3527
@gtpk3527 5 лет назад
@@joesterling4299 What he means though is specific meaning in systems operation in relation to causes. Instead of saying this is Bob's fault or Dave didn't do this job well, we need to look at why the system in place allowed Bob to commit that mistake or why Dave was in that position even though he as was not at acceptable skill level. That's the systemic vs human error. Obviously there's secondary question of negligence in criminal sense (if someone is drunk for example) but that still doesn't change anything on investigating the event. Those are two separate universes, so to say.
@drkjk
@drkjk 5 лет назад
The FAA being both the promoter and regulator of air travel is story 3?
@Dragonblaster1
@Dragonblaster1 5 лет назад
I am a quality professional who has worked in the aerospace and defence sphere for 12 years, as well as life safety equipment. I never accept human error as a root cause. How that error was allowed by the system to wreck the reactor was the root cause.
@cezarcatalin1406
@cezarcatalin1406 5 лет назад
Alastair Archibald Which is why human error is always the cause. But not just the error of the operators - especially the error of the ones who made the system. In Three Mile Island, the error made by the ones who made the system is that they didn't include redundant valves in the design and that they gave the operators the possibility of turning off the water injection pump despite the fact that it was an extremely important piece in the system. If you know humans do oopsies because of some bias or something don't let them do it - it should have been in the design. Besides this, those operators weren't even trained to run this specific type of reactor. Reactor designs are as many and diverse as there are types of cheese. Plus, humans under stress should be considered mistake generating machines. If you don't believe me, there is a study that tested groups of students by giving them a bunch of problems to solve in a fixed time interval. If for each group you decrease the time linearly, because we assume students to have some average computing power that tends to be constant in large groups, you would expect the percentage of solved problems to drop linearly as well - except the results drop much faster - it is because the students who had less time felt more stressed. The number of bad answers in the solved problems also correlates with the stress level. The lesson is simple - as a system designer, don't assume that a bunch of scared unprepared operators desperately searching the light panels and scrambling for solutions is an effective mechanism for preventing accidents. By the point we reach that phase, it is already too late.
@hardybirch3630
@hardybirch3630 5 лет назад
Refusing to accept human error as a root cause is a human error.
@ianrutherford878
@ianrutherford878 5 лет назад
@@cezarcatalin1406 Have you got statistics for that cheese comparison? I think you may have made the error of massive exaggeration.
@drkjk
@drkjk 5 лет назад
A backwash filtration system that clogs up the works didn't design and built itself. A leaking valve, known to create unreliable and erroneous information, didn't go un-repaired all by itself. The first issue may or may not have been understood by the design engineers, the second issue about the leaking valve was known and given a contemptuous hand wave. That, my friend, was human error.
@dickiewongtk
@dickiewongtk 5 лет назад
Can confirm, as a professional working in medical laboratory. The best way to eliminate human error is to eliminate human involvement.
@debt.2210
@debt.2210 2 года назад
From someone with no education in nuclear power, this was very helpful. Just enough information to explain but not overwhelm. And also, I like the not pointing fingers perspective. I am thankful we learned from TMI.
@gewgulkansuhckitt9086
@gewgulkansuhckitt9086 5 лет назад
I remember as a teenager when I discovered that nuclear power plants were basically hi-tech steam engines. My mind was blown. Up to that point, I'd always assumed that they somehow converted radiation directly into electricity or that maybe there was some sort of small-scale version of a nuclear explosion going on, with the explosion turning a turbine. I felt kind of stupid when I found out how it really worked.
@bronzedivision
@bronzedivision 5 лет назад
This is just popular extant power designs, alternate options exist. RTGs are common and aren't big steam engines. For more theoretical options, one could put a nuclear source at one end of a sterling engine to create power.
@johnstuartsmith
@johnstuartsmith Год назад
Do not feel stupid. "Stupid" is shorthand for "not being curious enough to question assumptions."
@neiltheplayer
@neiltheplayer 5 лет назад
I also came here for that story and left with a much better understanding of management and a good lesson too
@doc46vale
@doc46vale 5 лет назад
As a mechanical engineer, specializing in monitoring and control systems, I can see first some design faults in the monitoring system, thus the operating faults caused.
@xouber
@xouber 5 лет назад
outcome bias how are you doing ?
@KevinBalch-dt8ot
@KevinBalch-dt8ot 3 года назад
I’m a retired nuclear engineer that was in college at the time of TMI and worked in the industry just after the event. A very good synopsis.
@BackyardProspector
@BackyardProspector 5 лет назад
next time my manager give me crap, I'm going to be like "Hey, you are outcome biased"
@EduEnYT
@EduEnYT 5 лет назад
"Hey, you are fired"
@CGoody564
@CGoody564 5 лет назад
This doesn't even make sense regarding what outcome bias means...
@GabrielPettier
@GabrielPettier 5 лет назад
You are assuming he/she is the problem… you are stuck in 1st story.
@CGoody564
@CGoody564 5 лет назад
@@GabrielPettier for it to even make sense that he's outcome biased, he would have to know that giving him shit would improve his production, or he wouldn't waste time doing so and just fire him. This person clearly doesn't understand outcome bias as a concept.
@250txc
@250txc 5 лет назад
Yep, maybe you can be promoted to working inside and off the gas pumps outside
@pomonabill220
@pomonabill220 5 лет назад
That was an excellent presentation! Not only a detailed, second by second account of what happened, but how the "blame" should be handled and what should be accounted for, and not who!
@harmonicresonanceproject
@harmonicresonanceproject 4 года назад
That was such an exceptional presentation on so many levels, I think I'll be revisiting this over time. Thanks!
@DscntnuousMgntic
@DscntnuousMgntic 5 лет назад
Phenomenal approach to team functionality and relationships, this is the kind of mature and measured approach that can help our country become a better place to live. Reject blame narratives, avoid punish and discipline doctrine and candidly and swiftly address systemic failures.
@RussellFlowers
@RussellFlowers 5 лет назад
During the last few minutes, I imagined it was the Galactic Empire conducting a "Who Destroyed the Death Star?" presentation.
@RupertFear
@RupertFear 3 года назад
Nikolas Means needs a RU-vid channel. He is an excellent speaker, and educator.
@RobertGarveyATL
@RobertGarveyATL 5 лет назад
I found this to be an informative talk. I'm not getting into the controversy around nuclear power plants ... save to mention I am intrigued by the thorium cycle/molten salt technologies being developed recently. I just like the clear summary of the chain of events. And your discussion of the second story. I have a new entry on my reading list thanks to this presentation. Good job.
@robertbrandywine
@robertbrandywine 5 лет назад
Basically, the public has been told that the control rods can shut the reactor down immediately in case of an emergency (which is true as far as it goes) but we weren't told that even after the reactor stops reacting that there is a rise in heat which can damage the control rods.
@eaglesclaws8
@eaglesclaws8 5 лет назад
I swear our civilization will end with an assumption of being correct.
@aSinisterKiid
@aSinisterKiid 5 лет назад
i have a feeling at the end it will be a bunch of people trying to point the finger and place blame.
@Salmon_Rush_Die
@Salmon_Rush_Die 5 лет назад
Look around you.
@allgrainbrewer10
@allgrainbrewer10 5 лет назад
Like AOC?
@eaglesclaws8
@eaglesclaws8 5 лет назад
@@allgrainbrewer10 like your mom
@allgrainbrewer10
@allgrainbrewer10 5 лет назад
eaglesclaws8 are you 12? Go watch a Justin Bieber vid loser
@jhogan1960
@jhogan1960 4 года назад
I work in a water treatment plant and incidents like this echo some mishaps I have been through. Especially the decision making loops. And how you are judged in the post mortem of the accident.
@NikHYTWP
@NikHYTWP 5 лет назад
I watched your talk on the UAL DC-10 and now this, you're amazing and the stuff you talk about is really interesting!
@andrewharpin6749
@andrewharpin6749 2 года назад
This is a fundamentally brilliant talk, how have I only just seen this! This will be being shared around my organisation!
@thePhished
@thePhished 5 лет назад
I love how he did not vilify the engineers who had to make these decisions. A little perspective goes a long way. With a little hindsight bias, you could even say the events of three mile island were ultimately a good thing.
@herzkine
@herzkine 2 года назад
Nahhh, surely doing better is a better way then only blaming people. But that horrible midtakes were made and we ciuld havr done without all this is the core fact that shouldnt be forgotten also. Otherwise your consequence is glossing over not real fair critical forward thinking analysis.
@rrr92462
@rrr92462 Год назад
Outstanding explanation of the Three Mile Island accident. Best I've heard on yet on RU-vid.
@bernieeod57
@bernieeod57 5 лет назад
This is why I left the Sub force after serving 13 years. The nuclear Navy is constantly seeking heads to roll. Every day on board a ship was another day wondering if you were going to Captains Mast. I finally had enough. Not only did I refuse to re enlist, On my departure interview, I removed my Dolpins and threw them onto the XO's desk. I ended up "Finishing my 20" Actually did another 13 years) In the Reserves as an EOD Diver. One drill weekend, we had a uniform inspection. The CO stops in front of me and asked "Weren't you on submarines?" "Yes Sir! I WAS!" Came my response. "Where are your Dolphins?" "I choose not to wear them sir!" "Either you put them on or submit a request to have to Submarine qualifications stricken from your record!" Aye sir! It will be on your desk by 1630!"
@bernieeod57
@bernieeod57 5 лет назад
snipe69 The PEB was a copy of the ORSE nukes go through. Extending nuclear regulations into non nuclear areas was referred to as “Creeping nukism”
@bernieeod57
@bernieeod57 5 лет назад
@snipe69 Yep, and it got worse during the post Cold War draw down. The Sub Force was literally cut in half and all those Submariners were assigned to other communities bringing their "Nukism" With them.
@bernieeod57
@bernieeod57 5 лет назад
@snipe69 The XO of my last boat sealed my decision to leave active duty when he gave the following speech on the 1MC "Do not let Glasnost fool you! We are still at war! Only now that the Soviets are bankrupt, the enemy is dirt! Commence Field Day!" I submitted a 1306 to Go EOD and my detailer shot it down declaring "If we let everyone who wanted off the boats to transfer off, we would have to tie up half our ships for lack of crew!"
@11B30Inf
@11B30Inf 5 лет назад
What a wuss and a fucking cry baby!! You should have never join the military px warrior! Now fuck off!
@Swordsman52
@Swordsman52 5 лет назад
@@11B30Inf Stockholm Syndrome much?
@MervynPartin
@MervynPartin Год назад
The bulk of my career was spent in a nuclear power station, firstly in operations and later in engineering. I had heard it said on several occasions that if an incident occurred, it was an unofficial, unwritten policy to blame human error as it was easier to "retrain" an operator, than to carry out improvements to the plant that were the root cause of an incident. That is not to say that incidents were not initiated by deviation from authorised procedures. I have conducted the investigation into some incidents, interviewing staff, but never (I am glad to say) with the intention of assigning blame, but as in your presentation here, to find out why operators made sub-optimal decisions. This video presentation was extremely well done. if it is not already used in training facilities, then it should be.
@glennchartrand5411
@glennchartrand5411 5 лет назад
President Carter was also a Nuclear Engineer trained by Admiral Rickover.
@dragonsword7370
@dragonsword7370 5 лет назад
Carter was part of the reaction/cleanup team for the first nuclear disaster/accident. I think that was the small base reactor that cracked open and killed three... navy men I think? In canada.
@glennchartrand5411
@glennchartrand5411 5 лет назад
@@dragonsword7370 SL-1 was in Idaho.
@SCGATOR2001
@SCGATOR2001 5 лет назад
@@dragonsword7370 Carter was qualified on A1W in Idaho. He NEVER served on a nuclear powered submarine as he got out of the Navy shortly afterwards.. He was on a diesel boat and then entered nuclear training. I was NOT aware that he worked on the SL-1 reactor after the three workers were killed. Further research shows Carter got out of the Navy in 1953 after the death of his father. The SL1 reactor accident was in 1961. Therefore those dates kill the rumor that he was involved in the SL-1 reactor decon effort. The SL-1 reactor was an ARMY effort, not Navy. If you look at the SL-1 accident, it should be clear to anyone who was in Rickover's Navy program that RIckover would NOT have let that operation fly. Three men died unnecessarily due to incredibly poor practices. Rickover worried about details. The Army nuclear program apparently did NOT.
@glennchartrand5411
@glennchartrand5411 4 года назад
@CaliforniaCheez It says "Close Cover Before Striking Match" on a matchbook cover. He kicked a guy out of the program for not doing that when he lit a cigarette. (Failure to follow a written instruction)
@glennchartrand5411
@glennchartrand5411 4 года назад
@@SCGATOR2001 I was pointing out that "base reactor" accident that killed three operators was SL1 and wasn't in Canada , he was mixing details from two seperate accidents. Carter directed the cleanup of the NRX reactor meltdown in Canada in 1952 (Nobody died in that one)
@electrocarbid
@electrocarbid 9 месяцев назад
Wow, that was reeeealy interesting! Not just the details about the accident, also the paradigma of asking for the second stories. I will take this thoughts and include it into my daily work. Thanks alot.
@christopherkemsley4758
@christopherkemsley4758 5 лет назад
Extraordinarily-well done talk, sir!
@JonPrevost
@JonPrevost 5 лет назад
Sounds like a way to also deal with personal relationships that have soured from unaddressed ressentiments. Compassion for the "what" caused them to make that choice as opposed to waiting for them to own their mistake. Great talk!
@MrRandomcommentguy
@MrRandomcommentguy 5 лет назад
For my money, TMI proved the safety of US reactors under emergency conditions. It should have given everyone a confidence boost in nuclear power. I mean, yes, the operators made some basic and serious (but understandable) mistakes, but even so, the containment systems stopped the vast majority of radiation from escaping into the environment. Instead, of course, everyone freaked out and it was the beginning of the end of the US commercial nuclear industry.
@tookitogo
@tookitogo 5 лет назад
Simon Coles Well said, I couldn’t agree more!
@bronzedivision
@bronzedivision 5 лет назад
Indeed, but people fear things if they don't know how it works. And while I hate getting conspiratorial it's a bit obvious that coal and oil companies did a helluva job putting out fear mongering press during TMI and in the years after.
@MrFukyutube
@MrFukyutube 4 года назад
what you call fear mongering press is just advertising- reminds me of an ad for fuel oil from many years ago which was comparing oil heat to gas heat- they didn't come right out and say it, but it was heavily implied that having gas heat was a bomb just itching to explode and destroy your house, while oil heat was the only safe option, so worth the higher cost and less convenience.
@tomhuppi3949
@tomhuppi3949 4 года назад
The pressure vessel was not designed to take a melted core. Thankfully not all of the core melted, and that which did acted in an unanticipated manner which helped the structure remain in tact. It 'should have been' a different and much worse outcome. They/we 'got lucky' on that one.
@ethanweeter2732
@ethanweeter2732 4 года назад
Tom Huppi Why I believe in God. He could have let that cause a more serious radiation leak. Just like Chernobyl.
@AtabekZingi
@AtabekZingi 3 года назад
Psychological safety for your team, and foreward problem solving. What a great line bro ☺️
@shatterpointgames
@shatterpointgames 5 лет назад
I work in Harrisburg PA and can see 3 mile island from my desk at work.
@sleepwalker8496
@sleepwalker8496 4 года назад
Learned a life lesson watching a Nuclear disaster documentary... Well done .
@Eric_McBrearty
@Eric_McBrearty 5 лет назад
This was a good talk. So.. 1st story is told by someone who was around for the event but not actually there. 2nd story is told from a first person point of view by actual participants during an event. 3rd story is how we choose to document history. 4th story is an evaluation, analysis and interpretation of the history that we had chose to document.
@ResortDog
@ResortDog 4 года назад
I've been in a control room thats gone black with only emergency lights, annunciators & alarms more than once. System Operators are a special breed that dont get second chances most equipment failures.
@clayleto1719
@clayleto1719 5 лет назад
As an industrial valve technician, I'm always bothered when accidents are blamed on a valve. People created valves, people installed the valves, and people need to take responsibility for making sure those valves are properly maintained and functioning correctly. I've been in this field for 20 years and I've never seen a failure that wasn't caused by misuse. I can't build a valve that stops human error.
@andymonk9505
@andymonk9505 5 лет назад
Exactly, they like to blame instruments for human error.
@WadcaWymiaru
@WadcaWymiaru 5 лет назад
You need to blame reactor designer. Water was really bad choice...
@MichaelCampbell01
@MichaelCampbell01 5 лет назад
@@andymonk9505 Which they didn't.
@Starklar
@Starklar 5 лет назад
@zztop3000 or you just created a dozen new failure points - anything automated depends on a system - mechanical, digital, whatever. a good enough system could account for everything in theory(perhaps, remember that our theories might be incomplete since we also made them up) would still be subject to human error during design, construction and maintanance at the very least. Seems very logical that no human can stop human error
@johnbanas4353
@johnbanas4353 5 лет назад
These failures result from upper management ignoring proper maintenance in order to save money.
@WTFBODY
@WTFBODY 5 лет назад
This is a great presentation, and does a very good job of simplifying the TMI issues for common understanding. Regrettably, TMI U1 ended power operation yesterday. If the public understood just how much changed after TMI, it might still be producing carbon free electricity.
@davidmohr4606
@davidmohr4606 5 лет назад
Some of the outgrowths of the TMI incident was to install Reactor Vessel Level Indication System (RVLIS), more indications for Level/Temperature of the Pressurizer Relief Tank (PRT) and improved training on Thermodynamics and Reactivity control.
@scottn7cy
@scottn7cy 5 лет назад
The last 5 minutes of this video is incredible. The summation is true life wisdom. Very well done!
@WeaselJuice
@WeaselJuice 5 лет назад
This presentation is fantastic! 👍
@davidvarley9099
@davidvarley9099 11 месяцев назад
The best motivation for pursuing a no blame culture that I have heard.
@tbrasc0
@tbrasc0 5 лет назад
Very good presentation. Its also interesting to compare this with the decisions that were made at Chernobyl.
@tl4340
@tl4340 4 года назад
As a nuclear engineer with 20 years of experience, I can say that this was a very well done and accurate description of the TMI accident. The crux of the (pathologically wrong) operator responses is that their training (which came from the Navy) was (1) to never, never, *never* let a pressurizer go solid (i.e. all water and no steam), under any circumstances, and (2) the only reliable indication of water inventory in the reactor vessel is pressurizer level. The accident unfortunately had low pressure, low water inventory, and a high pressurizer level, which made them think that there was ::too much:: water in the primary circuit (exactly the opposite of what the actual situation was). The operators followed their training, but their training was very deficient. The regulatory agency (the Nuclear Regulatory Commission) and the vendor (Babcock & Wilcox) deserve as much or more blame than the operators. Fortunately, the nuclear industry had a revolution after this accident, forcing enormous changes in the regulatory, training, and safety analysis in the industry. Recognition of cognitive errors became a huge emphasis on training. Sadly we now see corporations like Boeing, Wall Street, and Big Banks that similarly engage in deficient business practices and whom have "captured" their regulatory agencies, and absolutely nothing is being done about it.
@GordWayne
@GordWayne 5 лет назад
Hell of a story, pretty incredible
@andrewcammer2535
@andrewcammer2535 4 года назад
What a great break down on the 3 mile accident, and then an even more important lesson in looking for the second story. Really thrilled I caught this!
@katout75
@katout75 5 лет назад
Great presentation, really explained the reactor, systems, events, and people that were involved.
@jimbob2810
@jimbob2810 5 лет назад
This is one the best talks on RU-vid ever. I just wish I could give a RU-vid video two thumbs up! Great presentation!
@copperhamster
@copperhamster 5 лет назад
The FAA/NTSB does this and most national aviation control groups in the world have followed suit. As an example, there was a flight in the 80s where a Chinese pilot violated a slew of rules and additionally got disoriented and caused quite a few injuries (two severe enough to require hospitalization), and several million dollars of damage to a 747 in mid crossing of the Pacific. It wasn't until he broke out of the cloud cover at 15k feet or so (iirc) that he regained control of the plane (within 5000 feet) and they then nursed it to a safe landing. He didn't lose his pilot's license. He didn't lose his job. He in fact got an award for having saved the aircraft after it had gotten in that situation, even though he 'caused' it. Because China, the US, Boeing, and China Airlines didn't want to blame someone, though yes, in the end, it WAS largely pilot error, but they wanted to know what happened, analyze the cause, and stop it from occurring again. The only reason they were able to determine the root of the problem at all was full cooperation of the crew, as the black boxes had recorded over their data (they only recorded 2 hours in a loop at the time, and the plane took more than 2 hours after the incident to land.) The crew cooperated fully because they knew not only that it was in their best interests, but that unless criminal negligence could be found (which would be intentional) they would be better off fully disclosing things than trying to hide things. In France, air accidents are treated as criminal matters from the moment of the accident. France has a large number of accidents where there are disputed facts, confused narratives, etc, because the air crews, ground crews, atc operators, can all face massive criminal penalties (They convicted one pilot of something like 18 counts of manslaughter or something, for example). Even in 'who gets the blame' environments I tend to operate by the principle of 'If you make a mistake, eat crow while it is young and tasty or you shall surely eat it when it is old and tough.'
@forecon11
@forecon11 5 лет назад
Tell that to the FBI
@calebcourteau
@calebcourteau 4 года назад
This talk is amazing. You did a great job telling the story Three Mile Island, but the skillful way in which you used it to illustrate systemic problems is even more inpressive.
@darrenmarchant1720
@darrenmarchant1720 5 лет назад
thank you for this excellent report.
@toma5153
@toma5153 Год назад
Dekker's book is highly recommended. In my career headway was made in promoting blame free accident or incident investigations, but never underestimate some operations manager's tendencies to jump into a blame game.
@jimvick8397
@jimvick8397 5 лет назад
The Anatoly Dyatlov second story would make musical... or ballet even...
@ChrisView777
@ChrisView777 5 лет назад
Yeah...you could definitely see him in a different light after this, he still was an arse though...apparently.
@slappy8941
@slappy8941 5 лет назад
I can imagine one of Dyatlov's songs... _"Not great, not terrible, but either way, you're delusional! It's like, a chest X-ray, so get yourself, to the infirmary!"_
@Swarm509
@Swarm509 5 лет назад
@@ChrisView777 Knowing his history before Chernobyl has to be taken into account, and the simple structure of the system he was working in. He still was totally at fault for doing the test the way he did the problems of the reactor being kept from him, and others, is what blew it up.
@krashd
@krashd 5 лет назад
@@Swarm509 But even forcing the test to go ahead was still a systemic failure elsewhere as in the USSR you either did your job or you had no job, do you think the only reason he rushed the test is because there was a football game on he wanted to see? No, the test had to be done on that day or it meant he was incompetent and not fit for his job. The only thing excuses got you over there was a bullet or the gulag. A systemic failing.
@nicolorau
@nicolorau 5 лет назад
there is in fact a long interview of him and is quite interesting if you hear his perspective
@Schm1dtstorm
@Schm1dtstorm 5 лет назад
I was not expecting rewarding management philosophies to come with nuclear disaster information, but it is certainly welcome! Incredible talk.
@chris-hayes
@chris-hayes 5 лет назад
I feel spoiled with my 9600 baud Arduino printout
@53toddk
@53toddk 4 года назад
Baud is a vastly misused term. What you really mean is bits per second (bps). Baud is not the same, except at a few very low numbers, such as 300, which is where the misnomer originated.
@gordybishop2375
@gordybishop2375 5 лет назад
Simple logic and common sense like this is so rare in most management. Something broken, work around it and get the glory of saving the company money....like money lost in shutdown to fix a leaky valve.( or money saved during construction by not having position feedback on critical valves )
@antoniovillanueva308
@antoniovillanueva308 5 лет назад
TMI is often viewed as a way of increasing accuracy. I have seen this over and over in many different places. The people who design a system frequently do not understand the mental implications of constant data overload on operators.
@user-si5fm8ql3c
@user-si5fm8ql3c 5 лет назад
Nuclear Energy is really complicated this is a official Training Simulator for Nuclear Powerstation ru-vid.com/video/%D0%B2%D0%B8%D0%B4%D0%B5%D0%BE-28HcalL_RFs.html
@anhedonianepiphany5588
@anhedonianepiphany5588 4 года назад
@@user-si5fm8ql3c When you state that "Nuclear Energy is really complicated", are you referring to the principles of nuclear physics or the actual operation of a nuclear reactor (as a part of electrical energy production)?!? Regardless, "Nuclear Energy" is _not_ particularly complicated, although individuals of average intellect (or lower) will likely fail to adequately comprehend much of the science involved.
@keenanfinucan8778
@keenanfinucan8778 4 года назад
"If you want to make small changes, change the way you do things. If you want to make major changes, change the way you see things." -Don Campbell
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