After many years of blogging, and consistent with my desire to move toward retirement, we have ended the Insights blog. Thanks to Doug Bedell for his years of blog support.

Learning from Adversity Should Occur Widely

Posted on June 3, 2010
Filed Under Technology | Leave a Comment

The technological disaster of our time is now the BP oil spill, not the Three Mile Island nuclear power accident 31 years ago or the Challenger rocket explosion in 1986. BP is a real disaster, while TMI (which we’re most familiar with) was only a perceived one. A mere $1 billion was spent cleaning up TMI Unit 2 after the uranium fuel in its reactor vessel partially melted. The damage at TMI-2 was confined to the reactor system and its containment building.

Both of us, Dennis Owen and Doug Bedell, worked at TMI during the Unit 2 cleanup and the restart of TMI-1. Dennis was a recovery engineer at Unit 2 and Doug was TMI’s post-accident communication manager.

The TMI accident effectively shut down construction of new U.S. nuclear plants for 30 years. Plants under construction were allowed to continue, and retrofits were ordered at operating plants once the “stuck-open-valve” malfunction was understood. Similarly, offshore oil rigs now operating should be closely monitored and possibly retrofitted when the problem at BP’s well is understood.

As turned out to be the case at TMI, cultural issues having to do with training and attentiveness – by employees and management alike – are likely at the heart of the BP disaster or, indeed, catastrophe. Why do we keep having to learn such things anew, at such cost?

Whether it was arrogance or ineptitude, not enough attention was paid to operational issues at BP’s oil platform. Newsweek is already making that clear in a gripping article, “Black Water Rising,” in its June 7 issue. A presidential commission will be investigating the accident, like the Kemeny Commission did after the accident at TMI-2.

When the Kemeny report came out, industry generally should have paid enough attention to its findings to avoid another costly accident, anywhere.

The now defunct General Public Utilities Corp., TMI’s owner at the time, was determined to learn all that it could from the Unit 2 accident, very much to its credit. Focusing on the lessons of the accident improved GPU’s corporate culture overall, and a strong, knowledge-imparting culture is essential to avoiding accidents. (Making wrong guesses about the direction of energy prices is perhaps another matter.)

The worst kind of situation at any company is to have the sort of “good ol’ boys” culture that Newsweek describes as having existed at BP and the Interior Department’s Minerals Management Service (MMS). “Oil guys know best” is nothing like having actual awareness of what can go wrong and how.

At TMI-2, the operators were misled early one morning by inadequate signaling on their control panels. They mistook a stuck open valve for an indication that the reactor’s cooling system had too much water when actually it was losing water. Better training as well as a redesigned control room were part of the answer then. But the biggest “gain” from that situation was the simple awareness that unexpected events can happen – to try to avoid them, but to be responsibly ready for them if they occur.

That, and to have effective regulation as well. In nuclear power, the Nuclear Regulatory Commission and its inspectors at the plants keep their distance from the industry, as the MMS folks apparently did not.

After the latest BP accident, President Obama asked Energy Secretary Steven Chu, a Nobel Laureate himself, “to assemble the best minds in America and get them down there.” Some of the best minds in America were assembled for John Kemeny’s commission on TMI-2. The problem is how we learn, and how widely we learn, from disastrous events and the findings they inevitably produce. This applies not only to operational managements but professional and trade societies as well.

NASA likely has the lessons of the Challenger accident seared in its institutional memory, as TMI’s staff and the Nuclear Regulatory Commission no doubt readily recall the Unit 2 accident. Learning from disasters, however, has to occur in a lot wider manner than among those directly involved. Suppose BP had paid attention, close attention, to the Challenger, TMI and, indeed, the Exxon Valdez oil spill. We don’t know whether they did or not, but if they did, it hasn’t been showing. – Doug Bedell

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Learning from Adversity Should Occur Widely

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