Systematic Failure | |
Despite the exhaustive efforts put into making critical systems
"failsafe", fail they do. The best example of this that I can think
of is the Three Mile Island accident. A modern reactor design with
considerable "defence in depth" suffered an incredibly unlikely
series of failures, omissions, and errors which conspired to
create what could have been a Chonobyl. The ultimate scenario
was avoided, not through good design and procedures, but people on
the scene thinking things through.
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General | |
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Aviation | |
Aviation is an area where failures are generally well studied
and copious amounts of information is available on the web. In
particular, the manner in which highly redundant systems still fail
is enlightening.
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Reactor Accidents | |
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1957 Windscale Pile 1 Nuclear Reactor Accident (air cooled reactor)
This was the first significant release of radioactive material from a nuclear reactor. It occurred while the graphite moderator was being annealed to release Wigner energy (distortion of atomic structure that results from the continual bombardment of neutron radiation, a effect that was poorly understood at the time). The energy was released too quickly and the uranium metal fuel and graphite moderator started burning. The fire wasn't immediately noticed due to inadequacies in the design of the monitoring system.1979 Three Mile Island Unit 2 (TMI-2) Reactor Accident (pressurised water cooled reactor) 1986 Chornobyl Unit 4 Nuclear Reactor Explosion (RBMK reactor) This is the stuff of nightmares - not the so much from the "oooh... dirty nuke go bang, bad bad" perspective, but the total devastation of the plant, the impact it's had on the Ukraine, and the sheer scale of the cleanup operation - an operation that can essentially never complete. One official web site mentions that around 25% of the Ukrainian state budget is spent on remediation of Chornobyl - and that ignores foreign aid. | |
Other Incidents | |
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A fire and explosion in a ship containing 2300 tones of fertiliser killed 576 people in Texas City - nearly 4% of it's population at that time. It's considered the worst industrial accident in American history.1983 radioactive pellets from radiotherapy machine mixed with scrap steel in Juarez, Mexico. A derelict radiotherapy machine is broken up for scrap. The Cobalt-60 pellets end up being smelted with other recycled steel and turned into 600 tones of reinforcing rod and table legs, which are then shipped to Arizona, California, Colorado, New Mexico, and Texas. The error was only discovered when a truck load of reinforcing bars sets off radiation detectors at the Los Alamos National Laboratories six weeks later.1987 radioactive pellets from radiotherapy machine stolen by junk collectors in Goiana, Brazil. In an almost identical incident, a gamma-ray radiotherapy unit in an abandoned building is stripped by junk collectors, and the source is cut open, extracting powdered Caesium-137. The powder is rubbed into the skin of several people, including children. The incident comes to light when they start showing up in local hospitals with symptoms of radiation poisoning. 4 people died, innumerable people were exposed, and around 3500 cubic meters of radioactively contaminated waste was generated.1996 Channel Tunnel Fire
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Andrew McNamara <andrewm@connect.com.au>