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

LeadDev · 762.1K views · 2018-03-21 · 37:07

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Overview

Nickolas Means recounts the 1979 Three Mile Island accident minute by minute, from the control rod insertion to the operator's decision to switch off emergency cooling. He argues that finding systemic causes is more useful than blaming individuals.

On Hacker News

HN recommends it whenever a failure is blamed on human error, as a clear case study in looking for the systemic second story.

Recommended by 4 HN people across 4 months · HN mentions 2020–2024

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What people said

lawrjone · 2021-02 · Strong recommendation

There's an excellent talk from Nick Means (GitHub) called "Who Destroyed Three Mile Island?". Link: [VIDEO] One thing it discusses is how the alerts inside the control hub were so noisy, and were logged via a reasonably slow printer, that the alerts which suggested the reactor was in serious trouble only printed hours after you could do anything. And the alert light that said "shits fucked" was placed right next to the light about an elevator being out of order. Human error is rarely intentional, and even if it is, a system that fails in response has missed the mark. The talk explains the amazing finds made by the government committee hired to investigate the incident, once they left the idea of 'human error' at the door. I do suggest you watch the video, but as a teaser: it turned out that at the time, most US nuclear engineers had been sourced from nuclear subs. Subs have totally different rules on how to manage the reactor, and train their staff inappropriately for a land-based reactor. Pretty significant cultural find...

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Huggernaut · 2020-10 · Strong recommendation

Nickolas Means has an absolutely wonderful set of talks on themes like this. Particularly relevant here I think, is his talk: "Who Destroyed Three Mile Island?" - which goes through the events that occurred at the nuclear power plant, the systemic problems, and how to find the "second stories" of why failures occurred. [VIDEO]

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tudorw · 2024-01 · Recommendation

Thanks for that, I really appreciated this breakdown of the accident at Three Mile Island and the concept of 'the second story' with regards systems thinking; [VIDEO]

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