How Non-Drama Becomes Super-Drama
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Photo: Flickr/Xurble
In Malcolm Gladwell’s “Outliers” he talks about how huge mistakes aren’t usually made by one error, but instead by multiple, compounded, uncorrected errors.
He relays the problems that led to the near total disaster at Pennsylvania’s Three Mile Island nuclear plant in 1979:
… There was a relatively routine blockage in what is called the plant’s “polisher”– a kind of giant water filter. The blockage caused moisture to leak into the plant’s air system, inadvertently tripping two valves and shutting down the flow of cold water into the plant’s steam generator. Like all nuclear reactors, Three Mile Island had a backup cooling system for precisely this situation. But on that particular day, for reasons that no one really understands, the valves for the backup system weren’t open. Someone had closed them, and an indicator in the control room showing they were closed was blocked by a repair tag hanging from a switch above it. That left the reactor dependent on another backup system, a special sort of relief valve. But as luck would have it, the relief valve wasn’t working properly that day either. It stuck open when it was supposed to close, and, to make matters even worse, a gauge in the control room that should have told the operators that the relief valve wasn’t working was itself not working.
Hence… near meltdown.
It took a LOT of non-dramatic, small-time errors to equal the near meltdown. It was nearly impossible, but the perfect storm happened.
Gladwell points out that they were very smart people who allowed small errors that added up. The perfect moment of unprepared carelessness and pride.
This is also how Goliath, Wall Street, NASA, and millions of marriages failed.
• What do we need to do now to prevent a near meltdown three months from now? •
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