Constance Perin

The premise of this book is that most the work done in the nuclear power industry is managing risk. Producing electricity is almost a by-product. She supports this conclusion with a detailed analysis of four events and their root cause analysis. As you can imagine, she finds many more contributing factors than found by the analysis, and demonstrates that the corrective actions will be ineffective at preventing repeat events. She notes that our root cause techniques are effective at fixing equipment problems, but don't solve people or organization problems.

One idea I found interesting was the suggestion that we need to tell events as stories. Each story needs to be told twice. The first time the event is described in a straight-forward manner exactly as it took place for the people involved. The second telling, reveals the conditions and factors that contributed to the event. She believes that this method will promote better understanding and effective corrective actions. This is exactly the methodology that the TV show Engineering Disasters uses.

Having done the work, I really, really liked the story of the thermographers with the hot spot on the transformer. This exact situation, and the calculation to support the understanding of the significance WAS covered in the training I received in year 2001.

Food for thought:
1. Who do you pay attention to; the new-comer with the different perspective or the old-timer who's seen it all?

2. Is "zero errors" a good target?

3. When faced with one abnormality after a long history of normality, do you try to prove or disprove the abnormality?

4. Is the nuclear industry 50 years behind the intellectual times and "up-tight" about non-technical studies?

This book is a tough read, with run-on sentences, commonly used words with special meanings and many many many quotes. But it's worth reading, even if you have to do it 2 or 3 times.… (plus d'informations)