How the wrong cat litter took down a nuclear waste repository
cen.acs.org
cen.acs.org
In Los Alamos, those charged with repackaging the waste were hearing a speech by an expert on the matter. The expert warned they should be using "INorganic cat litter", which they already were. What a member of the group heard was "AN organic cat litter".
The two look very different in print, but when spoken, they're often indistinguishable to a non-chemist. When the discussion made its way to memos and emails, the die was cast.
When that conversation happened, it should have ended with, "just to clarify, I should, or should not, use organic cat litter?" That would have cleared it up.
Furthermore, “It would have been much clearer if they had said an inorganic zeolite sorbent,” Hobbs says.
Wouldn't one argue that a better way to explain it would be to specify nonorganic kitty litter since that would clear up any confusion whether written or spoken?
I don't know. Spoken, "a nonorganic" doesn't strike me as clearly better than "an inorganic" at differentiating from "an organic". Perhaps if you knew in advance the qualififications of the intended recipient, but in a safety specification like this, you may not know much about who will be (mis)interpreting the directive. Specifying "an inorganic zeolite sorbent" in the context of nuclear waste may make it more likely that someone who isn't sure about the meaning of one of those terms will seek clarification. By contrast, I'd worry that specifying "nonorganic kitty litter" would increase the chances that someone will just ignore the essential qualifier.
Worse, the word "organic" is overloaded, and means different things to the general public than to chemists. Juxtaposing the chemical meaning with the vernacular "kitty litter" increases the likelihood that someone will misinterpret, especially when "nonorganic" is more commonly associated with marketing and "inorganic" with chemistry. In cases like this where a seemingly innocuous detail is actually of critical importance, it needs to be emphasis and redundancy. The oft-quoted rule of "omit needless words" is more applicable to fiction and journalism than to safety specifications. For something as crucially important as this, I probably would suggest something like "a chemically inorganic sorbent, such as a 'kitty litter' made from zeolite clay".
Really, how about having a specific written signoff procedure in place, where all supplies must be checked before purchase by a trained expert who knows the difference between organic and inorganic / clay vs wheat, signed off in writing against a checklist developed by experts, then checked again by a separate trained expert when delivered with another signoff, then checked again by a third export when actually used.
Multiple inspection is a known failure point. A thinks any errors they make will be caught by B and C. B thinks A knows what s/he's doing, and thinks any errors that slip by B will be caught by C. C thinks A and B know what they're doing and so no errors will have reached C.
The boss that recruited A, B, and C to their position pulled the most accurate workers from the shop floor - because you need the inspectors to be better than the shop floor.
Thus quality of product supplied to inspection is reduced; the inspectors are now very busy; and that leads them to shift product through (someone else will catch it; someone else has already caught the problems).
What you need is to give an accurate instruction, and to give people to halt if they're unclear what's meant.
The root problem here is that while the speaker may have been an expert in handling nuclear materials, they were not ALSO an expert in communication. The failure was the presumption that an expert can clearly communicate their domain knowledge across an expertise gap. Communication is a skill unto itself, one that often gets handwaved. People just assume they're good communicators because they can assemble a grammatically correct sentence. My wife is an editor. If I had a nickel for every time she's come home with a story about yet another coworker who claimed they "already edited their own paper and it just needs a quick look-over" and then handed her an incomprehensible mess, I'd have a lot of nickels.
Exactly. Also, it turns out flammable and inflammable mean the same thing -- I sure learned that one the hard way!
For some reason I'm reminded of a recent visit to Takashimaya, a department store in Tokyo. After making a purchase, the checkout operator asked me (in perfectly clear English, for which she unnecessarily apologised) if I would like it wrapped. I said yes (this was a gift). I was directed down the hall to another desk staffed entirely by a team that had apparently been doing nothing for the last eighty years but perfect the art of swiftly and flawlessly packaging objects in attractive wrapping paper.
edit: watch here https://www.youtube.com/watch?v=b6ltgrxioeQ
I have a feeling there are lessons here for the packaging of software, both from the nuclear waste story and the Japanese gift wrap.
Some jobs are menial, unattractive, dead-end slots in machines designed to squeeze the youth from you. Motivation and morale matter, and maybe some people are cut out to find their niche early, but many are so painfully not. So what to do about that?
I think it is a very unhealthy point of view to expect that a single individual perform a single mundane task repetitively and nothing else; sadly it is a common pathology of organisations that many such small roles are used to assemble a larger system.
I'm reminded of an extreme case of this every time I traverse a US airport, where there always appear to be far more staff than necessary (especially compared to the majority of airports I transit in Asia, Europe and Oceania) but none of them can assist you with any other part of the system they comprise, leading to many small systemic failures that leave inexperienced travellers confused, late, lost, even detained; and occasional large systemic failures like those recently in the press.
This is also how many organisations develop software, particularly enterprises & government, and is a partial explanation for the resulting shitshow.
As for what to do about lost potential, I think the answer is the same it ever was: universal education, universal healthcare, eradication of poverty, eradication of conflict, and this a great way to annoy the Randites.
Large retail operations in the United States do well at supply chain efficiency, but the last mile is still pretty desolate and miserable. There are still signs of life in smaller or more careful operations, but most corporate store fronts are filled with hateful misery, and I remember being a part of it and feeling all the reasons to hate it, for several years of summer jobs.
I didn't even catch the taste of a vaguely desirable job until my late twenties, and I think I'd choose death over a backslide. Having to face radiation, on top of surrendering 40 hours of my waking life, all while watchng how others live across the internet and on TV, I'm sometimes baffled by the safety of anything at all.
There are downsides to groupthink, too, though; as a perhaps extreme example, the Fukushima disaster has been partly blamed on the resulting aversion to questioning a status quo.
Here in Australia, and also in the US, I think some managers are not happy until they've reduced every job to a process job. There are still companies where this is not the case, and if you cannot find one, it is also easier here to start your own.
I'm so glad to see someone else mention that! It always makes me think that the US is a communist state in disguise when I see all the unnecessary people in US airports.
It hasn't caused any major problem for me yet, but I expect that day will come.
In other words, when failure is not an option you have to engineer out failure vectors. This was stupid simple to prevent. I don't see it as a failure of the workers, they don't know any better.
As an example, in aerospace you vet and qualify every single material through Material's Engineers. Only materials that have been approved for a particular use are designed into an assembly. It would be inconceivable for an assembly technician to order an alternative adhesive from a random catalog. This is proper engineering.
It sounds like the folks running the nuclear waste installation had no idea how to manage a mission critical process.
Oyster mushrooms can be grown on lots of "plant based" substrates. One easily available substrate is kitty litter made from recycled newspaper, such as the "Yesterday's News" brand. If you to use a zeolite based litter here (even if it had organic certifications) your mushrooms would grow poorly if at all: http://www.namyco.org/docs/grow_oyster_mushrooms_on_kitty_li.... But for bonsai, both clay and recycled newspaper would be a disaster. Here, you need a litter made from "diatomaceous earth", such as Tesco's "Low Dust Lightweight Catlitter": http://www.bonsai4me.com/Basics/Basicscatlitter.htm. Tomato seedlings have about the same requirements as bonsai: http://www.tomatoville.com/showthread.php?t=22329.
I mention these partly as a joke, but there actually is a deep commonality here. All of these are real world situations where the specific type of cat litter used has implications, and in all of them, despite the authors' strong desire for precision and clarity, you find forums full of people who take the "shortcut" of using the wrong type of cat litter and then complaining that it doesn't work. I'm not sure what the solution is, but in the future it sure would be great if we could troubleshoot the instructions in the mushroom, tomato and bonsai communities rather than jumping straight to nuclear waste disposal.
Does anyone have examples of other communities making odd uses of specific types of kitty litter?
Might save some grinding, at any rate.
> Investigators traced a series of internal communications in which the specifications for “kitty litter/zeolite clay” were transformed into “kitty litter (clay),” the report says. Combined with inadequate technical review, this resulted in LANL workers filling waste containers with a mixture of nitrate salts and sWheat Scoop, a cat litter that is 100% wheat, according to its manufacturer.
1. Don't use jargon.
2. Remove unnecessary words.
3. Write a third grade level.
So someone comes along and sees the phrase "kitty litter/zeolite clay" and decides that its author does not know how to write based on its author not following the rules and applies syntactic rules without understanding the semantics (in this case the semantics of nuclear chemistry).
My suspicion is that someone was sitting on a big pile of wheat waste, which unlike fill dirt is organic and probably goes bad and probably needs to be moved off the wheat processing lot for next week/month/year's wheat harvest...and the wheat waste (unlike fill dirt) probably needs to be disposed of properly in a sanitary landfill and that's some more expense.
I mean at some point, someone is probably paying to have the wheat waste hauled away, whereas zeolite and other clay minerals are typically mined deliberately.
Your suspicion sounds plausible, but looks to be directly contradicted by the Department of Energy's post-investigation report. To the contrary of this being a decision made by the low cost bidder, the problems with the process started with a mistake in the specification that was produced by Los Alamos National Security LLC, the private company specifies the proper operating procedures at the national lab:
"When LANS began using this procedure to process nitrate salt wastes in September 2011, it did not perform a USQD [Undetermined Safety Questions Determination], as required, because the change from inorganic to organic absorbent was incorrectly determined to be an administrative (minor) change."
"In one particular instance, a conduct-of-operations SME [subject matter expert], working outside of his/her area of responsibility, added new text to DOP-0233 that included using organic kitty litter as an absorbent, as opposed to the inorganic zeolite material discussed previously in technical team meetings."
"In the previous example, the SME's addition of the text to DOP-0233, Section 10.6, which included the word 'organic', was submitted informally as a 'minor' comment, rather than an 'essential' comment that would have required explicit concurrence from the entire SME team."
Unless the report is wrong, or unless the SME who made the change was actually working in deep cover for a kitty litter producer with a surplus of wheat, this looks to be an error of knowledge and process, not a cost-cutting measure by a low bidder.
https://energy.gov/sites/prod/files/2016/02/f29/Posting%20co...
Normally for government specifications, opportunities to enjoy pitches by vendors to have their products added to the specification are not allowed due to the potential appearance of a conflict of interest. On the other hand, an LLC might not have quite as rigid a protocol...and establishing an LLC might even be done to avoid having rigid protocols around bidding and vendors.
Now I could be completely off base and a low level employee went cowboy all on their own due to some previous knowledge of organic kitty liter and the economics of its bulk availability. The center of the distribution when specs get changed to allow an alternative technology is more commonly customer eduction by vendors.
Remember, kids, if you receive a sentence that's ambiguous, you can't edit it to make it less ambiguous if you don't have an extrinsic reason to know what was meant. Blindly editing can only destroy information, not create it (also known as the autocorrect problem).
Specifying a generic or branded product for an off label use is just a bad bad idea. Because the manufacturer of kitty litter can't be counted to control for any properties other than those reflecting use in a cat box. Fatcat(tm) Unscented Kitty Litter might be fine until one batch shows up that's 95% zeolite clay / 5% sawdust.
First, if you really need zeolite clay you can't use the shortcut term since someone will complain to the IG that you stupidly overpaid and wasted the taxpayer's money.
Second, relatedly, some vendor will sue because you specified a "hammer" but didn't specify the material, thus overlooking their cheap plastic hammer.
And as a result we end up with the $600 toilet seat.
1. Jargon is acceptable
2. What words are "unnecessary" is quite context dependent
3. You write to your intended audience.
One of the best ways for that is to use soil and hot-fired clay / diatomaceous earth. Which is not really easy to find as a product. Funny enough cat litter can be just that. However, there are many cat litters out there which are made from a wide variety of things. So it's really difficult to eek out the right stuff.
Like the article says it can be organic material, or it can be clay that turns to mush when it gets wet. There are other materials out there though, like Turface, which is always high fired clay, or oil-dry materials from auto supply stores, which varies a lot like the cat litter.
Either way it kind of seems insane that they are acquiring this material instead of finding a direct and reliable source for the exact material they want.
"An October 2014 report from the Department of Energy’s Office of Inspector General points to a change in the packaging procedure at LANL that specified organic cat litter, when an inorganic sorbent was likely intended. Investigators traced a series of internal communications in which the specifications for “kitty litter/zeolite clay” were transformed into “kitty litter (clay),” the report says. Combined with inadequate technical review, this resulted in LANL workers filling waste containers with a mixture of nitrate salts and sWheat Scoop, a cat litter that is 100% wheat, according to its manufacturer. “It would have been much clearer if they had said an inorganic zeolite sorbent,” Hobbs says. “It’s been a very expensive mistake, costing at least half a billion dollars.”
And I'll need to bookmark this just for the lack of points and the deafening silence, for the next time I see some grandstanding on HN about luddites being paranoid about nuclear waste and dumb one-off accidents.
> LANL generated nearly 700 drums with a similar waste mixture that includes the organic cat litter. Drums with similar mixtures were isolated and are monitored, DOE says.
> “Why didn’t more than one drum react as that drum did?” Hobbs asks. “Never to my knowledge did we firmly establish that there is something completely unique about 68660.”
It's an interesting puzzle, but not one for you and me to worry about. Vote Vault Tec.
Now, what was the actual problem encountered at the site?
And howw would you go about determining that a benign vs. concerning situation had transpired?
A large part of why nuclear power is so expensive is because safety is considered so important. It's hard to get good numbers, but chances are more people have died constructing reactors and mining / refining ore etc. than from nuclear accidents. The difference is simply what people are less concerned when a heavy object falls on someone else.
The deaths from particulate emissions are not even necessarily the biggest problem with coal: if you price out the externalities, the cost of climate change (from CO₂ emissions) is the biggest item [4].
[1] http://www.catf.us/resources/publications/view/138 [2] http://www.catf.us/resources/publications/view/8 [3] http://www.ourenergypolicy.org/wp-content/uploads/2012/06/hi... [4] http://xhxhxhx.tumblr.com/post/157192261427/alright-two-impo...
What we should worry about is how critical systems go wrong in human hands - even in the stupidest of all possible ways - since there are more critical systems by the day. Genghis John's limit on maintenance and attention nears... yell it from the mountain tops!
[0] https://news.ycombinator.com/item?id=14355072
[1] https://en.wikipedia.org/wiki/Radioactive_waste#Management
Might be not dead over here, but it certainly isn't healthy.
I am a larger proponent of renewables in almost all forms, but they all share one really critical problem: they can't promise to scale to meet short-term spikes and drops in demand. For that, you need a fuel-based form of energy, and of those, nuclear is still the best we have.
(But demand for fuel energy can be reduced by rushing as quickly as possible to large-scale renewables and new energy storage technologies, and I hope that happens.)
http://www.gridwatch.templar.co.uk/
http://www.gridwatch.templar.co.uk/france/
But nuclear generation could improve its economics and reduce the use of inefficient fossil fueled open-cycle turbines/spinning reserve if battery storage becomes more common and nuclear electricity recharges the batteries for meeting daily peaks.
It seems like a statistical-awareness failure, like the people who won't fly because they're afraid of terrorists even though driving is far, far deadlier.
I mean, let's grant all that, let's say nuclear energy is 100000x more clean and safe and cheap than all the alternatives. Then why not discuss this curious thing about this most lovable of energy forms? Seriously, I thought the best stuff in science happens when someone goes "hey, this is interesting..."
If you love or even just like a thing, kick its tires!