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HUMAN_ERROR
May 20, 2008
A common error people make is
to distrust the very idea of It's a well-recognized
automatic safety systems. cognitive bias: people
like to feel like they're
For example, they worry about whether in control, hence they
a nuclear power plant will really virtually ignore the
shut down automatically in the case risks of errors in car
of trouble. driving, but panic
about every reported
But getting that kind of airline crash.
failsafe behavior to
work is really pretty
trivial as engineering
problems go.
Sept 03, 2013
I was working at the Nuclear
Research Facility at the INEL when Fukushima turned out to be a
a small earthquake hit: all of the contrary case: the tsunami
reactors that were running shut was bad enough to take out
down automatically, as they were the emergency pumps needed to
supposed to. do a shutdown.
It was also not the problem at How it is that this was
Three Mile Island: the automatic possible remains an open
systems saw rising temperatures and question as far as I know:
shut the plant down multiple times. did they know about the
vulnerability and
The trouble was that procrastinate on fixing
the human operators it? Did they feel no need
continually did to worry about a tsunami
manual overrides of on this scale?
the safety systems.
They looked at the And interestingly enough, once you
low pressure gauge point this out to people they tend to
readings and assumed feel better about the TMI accident.
the high temperature
readings must be bogus. They *like* the fact
that there were
They were in the process screwups by the
of switching to fancy new human operators.
computerized temperature
measurements, and trusted But this hardly
the lower tech pressure let's the nuclear
gauges more. industry off the
hook: if human
And the operators had been beings are part
trained that pressure and of the control
temperature would always go loop, then the
up together: but that's reliability of
*only* true if there's no gas the whole system
bubble in the system. Gas is depends on those
springy and compressible, and humans, and you'd
it makes it possible for the better have some
pressure in the water to stay way of making
low when temperature goes up. sure they *don't*
screw up.
So we need social systems
(training and management) that
create an institutionalized
commitment to safety and
ensures that the operators are
well-informed and competent.
As is often the case:
the social component
is the hard part of
technical problems.
TECHIES_FALLACY
But then, in the
case of TMI the
problem was largely
self-healing.
Afterwards no one would
would dare shrug "oh,
it's probably a false
alarm."
Nothing like
trashing a
plant to
convince
that it's a
good idea to
take every
warning
seriously.
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