Poor KM Led to a Nuclear Accident

27-May-03

This is a very interesting paper about how inadequate risk awareness and the « kaizen » production improvement philosophy led to a catastrophic accident at the JCO uranium processing plant. I liked the analysis of “human error” and the authors’ declaration of this conclusion as insufficient. They go deeper into vulnerability causal factors and trigger causal factors. They also discuss participative and reflective openness as two distinct but essential conditions for good KM.

Details

Attachments: 1

Author:
Andrew Lewis
Publisher:
KnowledgeBoard
Date:
27-May-03
Categories:
Critical Incident Management, Critical Incidents Management 
Sections:

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Member comments (8)

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Andrew Lewis
Andrew Lewis, 19-Jun-03 @ 08:59AM
Inflexibility of both sides of environmental debates

Though I consider myself an environmentalist, conservationist, etc., I am often dismayed by the self-righteous inflexibility and myopia of the environmental activists, which is only rivalled by the attitudes of their corporate adversaries. In this case, the refusal of environmentalists to allow nuclear waste anywhere has led to it being stored unsafely everywhere. It reminds me of the environmental campaign against the Eskimos’ clubbing of seals for pelts in the 80’s and 90’s, which has since led to the destruction of the Eskimos’ livelihood, an imbalance in the ecosystem, and free reign of oil companies in the absence of the Eskimos’ resistance. Obviously, this is one more piece of evidence that corporations will stop at nothing to make a buck, but I think that in this battle of extremes, agencies such as the EPA or even UN agencies need to take a stronger role in order to enforce reasonable compromises.

Chris Macrae
Chris Macrae, 18-Jun-03 @ 10:57AM
who's side

I wonder who's side you'd be on in this whistleblowing story http://www.alternet.org/story.html?StoryID=16097

and how do we read between the lines of what's happening here?

Chris Macrae
Chris Macrae, 11-Jun-03 @ 09:45AM
bravo Pravda's Accident's Web

In surfing Pravda today, I thought it excellent that 'accidents' is one of the primary columns this newspaper's homepage themes (communal learning around)

Do we know any other nationwide or worldwide newsportal which tracks back histories of accidents and whether anything was learnt from them in such a public way?

Within a click I was reading what has and hasnt still be learnt from Chernobyl at eg
http://english.pravda.ru/accidents/21/97/384/9824_Chernobyl.html

Andrew Lewis
Andrew Lewis, 10-Jun-03 @ 15:55PM
Disaster Preparedness

Hi Helen and Chris,

Perhaps it would be worth signposting this “Poor KM led to a Nuclear Accident” article as people have found it quite interesting.

Chris,
As far as disaster preparedness and resilience, I think there is some good work being done by the Federal Emergency Management Agency (www.fema.gov) and the Homeland Security department in the U.S. On the FEMA site, they have a section “Spotlight” which has a bunch of information on preparing for critical incidents. I imagine that other countries have similar information available, but it is less visible on the web. I know that Paris has a very clear set of protocols that are activated whenever there is a situation of increased risk.

Regards,

Andrew

Helen Baxter
Helen Baxter, 06-Jun-03 @ 04:53AM
If you need anything like this highlighted

then send me the location and I'll signpost it to the community.

Chris Macrae
Chris Macrae, 05-Jun-03 @ 11:39AM
can kboard have a lessons page

It seems to me that as K'board grows up we need to find ways of cataloguing the most interesting threads in our history, even if Helen has to do some occasional extra programming by hand. I would vote for a page of links to big lessons; and start the menu off with this nuclear thread. Over time that might encourage sigs to think of whether they have cases which have huge long-term value as a knowledge cluster even if their specialism means that the conversation they prompt is quite spasmodic, and therefore they are likely over time to go to near the back of any sig's library in a space that has little visibility. I will send Helen a copy of this thought.

It would also interest me to hear some votes across all the sig boards of what other biggest learning cases we have featured somewhere.

cheers
chris

whilst I am writing, I am wondering if any of us know of any webs built by cities as best examples of how all business intelligence needs to flow in to an epicentre as a way of making the city resilient to terror crises or other citywide breakdowns; London is starting down this journey and could benefit from any links to specialists who already have working examples webbed

Andrew Lewis
Andrew Lewis, 05-Jun-03 @ 08:39AM
Looks like the JCO lessons were dissemminated

Hi Chris,

I took a quick look into the sharing of lessons learned following the JCO incident and it appears that efforts were made to share those lessons. This is a link to a communiqué from the Nuclear Energy Agency on a conference that they organised following the incident: http://www.nea.fr/html/general/press/2000/2000-09.html
However, I don't know to what extent this communiqué really represents the situation. Perhaps some of the other SIGs will have ideas? NGO or Public Sector SIGs?

best,

Andrew

Chris Macrae
Chris Macrae, 03-Jun-03 @ 17:04PM
very useful case

Thanks for putting up such useful content. I wonder if there is a danger of the same sort of accident happening in another country. Usually, I would have thought of Japan as a very unlikely country for such an accident. Do we know what sorts of other countries are involved in similar procedures and is this particular expert community openly enough networked that all of these plants will have learnt from this case?