Safety lapses hobble Los Alamos National Lab’s work on U.S. nuclear warheads
sciencemag.org
sciencemag.org
Yet again serious problems happen due to the Normalization Of Deviance. We really need to find a way to create working conditions that encourage correcting problematic situations immediately before the behavior becomes normalized.
Regarding the management/other problems... I encourage everyone in ever industry that is ever involved with safety (i.e. most industries) to see Richard Cook's short talk about "Resilience in Complex Adaptive Systems"[1].
The list of nuclear accidents is hair-raising. The thought that a co-worker might assemble a near-critical mass nearby is... beyond hair-raising. Where the heck are they getting these guys, and what are they telling them?!
In your root cause analysis, 99% of the time the answer should not be "human error". An error that one human makes will be repeated in the future by another human.
The problem is setting up patterns and processes in the working environment that are aware of these human limitations and that work around them. The air travel industry is a _great_ example of what happens when you don't simply blame the human, but look to fix the true problems that caused the human to make a mistake.
Contrast to my company:
Our phones require you to dial "9" to get out of the building, and then "1" to dial long distance. A lot of my coworkers are foreign and in the process of trying to dial a cell phone number (international or otherwise) accidentally dial "911". When they realize their mistake, they hang up, not having grown up in America and learning to stay on the line and tell the operator that you made a mistake.
Company response? Threatening emails, verbal and written company-wide wrist slaps, and stickers on every phone that say not to hang up if you dial 911 or you'll get in trouble.
As a result people are now afraid of dialing long-distance numbers and so they simply avoid it.
Imagine if the company had instead tried to correct the true issue causing the errors (poor phone routing numbers)?
I explained that it was a mistake, and they said not to worry about it and hung up. No officer was dispatched.
I wonder if something has changed since I made that mistake, if it's just inconsistent across the country, or if there is some discretion of the dispatcher to decide that the child probably did make a mistake.
http://www.npr.org/sections/health-shots/2016/06/17/48220344...
The author buried the lede.
It must be pretty hard to disrupt the "government contracts for nuclear weapons production" industry..
not to pick on you, but this is an interesting turn of phrase (I know it is sarcastic). There is an interesting gulf in SV culture nowadays between needing to "disrupt" an industry, and the industry actually just needing some renewed competition. A major problem is usually raising enough capital to really compete. And an interesting SV and banking assertion often made is that there is way too much capital chasing too few opportunities.
I guess that raising relatively small VC funds precludes putting large sums of money to work, because that means no diversification. On the other hand, if we are done with low-hanging-app-fruit for outsized returns, is the solution just to raise bigger funds? It seems there are problems that can be profitably solved with modern software, modern teams, and new ideas, but which are not solved due to too much diversification of capital.
edit: fixed autocorrect and word choice.
Another issue that plays into diversification is the inherent riskiness of startups. Most will fail to create so much as a decent app while remaining on budget, who do you trust to create a reliable nuclear research lab? Even experts in the field might not have the requisite business experience, and if it fails it fails big time. You need someone like a Musk or Bezos to obsessively drive such an endeavor, and it's hard to pick out the future Musks and Bezoses if they haven't already proved themselves.
I don't particularly like the word disrupt, but I used it in this context because HN knows exactly what I mean when I use it..
I suppose I did actually mean "healthy competition" or "re-thinking" and not necessarily the true meaning of the word.
It reminded me a bit of some of the Discovery Channel's shows where they stress that if this multi-million ton container ship doesn't stay between the two entrance markers to the harbor, it kill everyone on board and probably destroy millions of dollars in goods. The entrance markers are 5 miles apart. The fact is accurate, the narrative is not.
If you want to be really scared go read the OSHA reports on any of DOW's chemical plants. I would be willing to wager that more people have died in the last 5 years of industrial accidents at their plants than all of Los Alamos. The Union Carbide Bhopal disaster killed over 2,000 people, one accident.
The point is the article was not written to compare the risk of accidents at Los Alamos to that of other similarly sized industries, nor was it written to highlight the misalignment of lab management with safety goals. It was written to characterize nuclear materials as scary and dangerous and carefully avoids any way for the reader to compare that risk with other risks they are both familiar with and are not concerned about.
In short, it is anti-nuclear propaganda.
Well yes, global logistics is incredible, the ship is working fine, the weather is good and there isn't a us destroyer for miles so of course they will.
I wish they'd just focus on the engineering and logistics and cut all the bullshit.
I'd also really love it if they'd take a swan dive on specific areas, navigation, maintenance, scheduling all that stuff.
If they made documentaries I'd like they probably wouldn't have many viewers.
Deadliest Catch was good in that regard, some interpersonal stuff (more in later seasons) but the barent sea is dramatic enough alone.
https://www.youtube.com/watch?v=41QMaJqxqIo
This is a great idea. I wish more of the more serious post-mortems were this thorough in our industry. But I guess people rarely die, they just have millions of peoples data leaked or result in serious service interruptions, so we don't have much of an incentive.
The unpleasant death of Louis Slotin [1] is an example of the risks these people were taking.
[1] https://en.wikipedia.org/wiki/Louis_Slotin#Criticality_accid...
I'm not a physicist, but as far as I know the blue flash generated by a criticality is caused by gases in the air fluorescing. Cherenkov radiation is a different phenomena.
Edit: Seems to be confirmed by [1] https://en.wikipedia.org/wiki/Criticality_accident#Blue_glow
That's a pretty alarming idea!!
Astronauts have reported seeing flashes of light when they close their eyes in space. It's believed to be caused by Cherenkov radiation from cosmic rays traveling through the vitreous humour of their eyes.
Source: https://www.nature.com/nature/journal/v228/n5268/abs/228260a... https://www.ncbi.nlm.nih.gov/pubmed/12678106
Essentially, they used a chemically incompatible kitty litter in bins of nuclear waste (I read another article somewhere that went more in depth about how the decision to switch went down...unfortunately I can't find it quickly, but I recall it had something to do with a lack of clarity in communication). That bad reaction caused the bin to explode underground in the Waste Isolation Pilot Plant and release radioactivity.
Shortly before this event, there was a truck that caught fire underground at the waste repository, shutting down operations. I think that event happening kept the amount of workers exposed in the bigger incident down.
From my experience, safety in these sorts of situations is more of a burden than a lifestyle from a worker perspective. Holding individuals _and_ their superiors accountable--not only those that do not follow safety practices but also supervisors--I think is the only way safety will actually be fully practiced.
https://www.amazon.com/dp/B00C5R7F8G/ref=dp-kindle-redirect?...
There were also many stories where a weapon was dropped during loading or caught in a fire, etc., and the general idea seemed to be that it could just have easily ended up in disaster.
The story of the Damascus incident, which served as the framing story for the rest of the book, also seems relevant. In that case there were procedures to ensure safety but over time the reasons for these procedures seemed to have been forgotten or the knowledge inadequately passed on to newer team members. Old equipment (like HAZMAT suits) were allowed to get old, rendering them useless. Many people in the administration chain had weak or little knowledge of the facilities... And then there was an accident where a small mistake compounded into pretty scary incident.
And it's not so. An individual can be lucky, but it's not something to be approached with "don't worry". The proofs are in Eileen Welsome's "The Plutonium Files: America's Secret Medical Experiments in the Cold War"
https://en.wikipedia.org/wiki/The_Plutonium_Files
Much more depressing than Mahaffey's book.
And example of the attitude of these responsible, Welsome, speaking in 1999:
https://www.c-span.org/video/?153507-1/plutonium-files
"Los Alamos National Laboratory told me they knew nothing about the experiment and in fact denied that it occurred even though it was a subject of the congressional report in 1986."
Another related story https://www.washingtonpost.com/world/national-security/safet...
"Huh, if I bang these rods on each other, I see a flash of lights showing it was 50% to critical, I hear the Geiger counter jack up, and my radiation badge measures that I've just instantly received a year's worth of radiation. Ouch."
Maybe if technicians could experience first-hand how easy it is for these plutonium rods to go critical, they might be more wary of mishandling them. It's understandable how a person could become desensitized to the risk of something that they've never seen happen, where the threshold of that event occurring is not intuitively known.
When I'm driving my car in a high performance way, I can feel when I'm beginning to push the bounds of its traction. I can feel when antilock breaking kicks in. I get to experience the threshold where something bad can begin to happen. With fissile material, perhaps it is a problem that workers never get to experience the threshold boundary at all until it's too late.
Edit: upon thought if I was anywhere that had a rod laying on a table I'd get the hell out of there as soon as possible, cause it's just a recipe for disaster
I wonder if having another facility that can perform this work wouldn't provide the right incentive for the underperforming unit to improve. Competition is a healthy thing. Knowing that there is another lab that is doing the work to specifications should provide good motivation to improve.
Armed forces around the world rely on esprit de corps. The British SAS don't have to compete against Navy Seals to know they are the best, they know already.
You'd ask just how a nuke technician could even think of getting close to assembling a critical mass. Are they really that dumb? Have they never been told?
Every ship drilled to maximize their rate of fire. Commanders of vessels who could not keep up with their peers were sacked.
When the Battle of Jutland came around, the Royal Navy greatly outnumbered the Kreigsmarine, and caught it unaware. The engagements were incredibly in the United Kingdom's favour.
Numerically, the battle was a disaster for the Royal Navy. Its losses were double that of their opponent. One of the reasons for it was that a number of RN ships exploded after taking a single hit - while German ones took shell after shell, and stayed afloat.
In their zeal to optimize their firing rate, the Royal Navy did away with the simple precaution of installing airlocks between their ammunition storerooms, and their gun rooms. You see - opening and closing an airlock every time you needed to get to and from the ammunition room wasted too much time.
Hitting a German gun room would destroy the gun. Hitting a British gun room would destroy the entire ship. But boy, did those gun crews shoot fast.
Unless your competitive process rigorously accounts for every form of cut corners, you're going to get what you measure... With some shortsighted optimizations thrown in.
See The Rules of the Game by Andrew Gordon if you have an interest in naval history or how large organisations respond to change.
It is a way to incentivize and improve efficiency, but it can also be a very expensive way to do so. It requires a lot of redundancy. You're effectively doing the work multiple times in parallel and discarding the loser.
That's fine when you're talking small farmers growing strawberries who can switch to another crop if it turns out their strawberries aren't good enough.
But running multiple nuclear weapon processing facilities simultaneously and pitting them against each other is an insanely costly way of improving safety.
France has the right model with nuclear power creation and generation through a vertically-integrated state owned company, Areva. Our stockpile has to be an effective deterrent. We shouldn't trust contractors with our stockpiles, that process should be vertical too, damn the costs involved.
What's most irritating is that the DOE use a broad brush and go overboard where it's easy and clearly don't do enough where it's hard. I had to attend ladder training before I was allowed to climb down under the 4' floor in my computer room and the rule was made that we had to use ladders all the time. You can't even fit the ladders in the tile holes, but the rule was on the books because it was "safe!". There were so many of those boneheaded rules, but these boneheads are allowed near plutonium to photograph it for no scientific purpose? Grrrrr
What should happen, in my opinion, is the University of California, and all contractors and corporations, and employees and workers, should be fired, banned from industry permanently, and the entire system replaced, because none of this, as the article points out, are isolated incidents, but rather are systematic and endemic problems.