5 ms·

Missing from this article is the most fascinating thing about this story- why someone thought it was a good idea to make the cat litter substitution that made t

Missing from this article is the most fascinating thing about this story- why someone thought it was a good idea to make the cat litter substitution that made this whole mess possible. In Los Alamos, those charged with repackaging the waste were hearing a speech by an expert on the matter. The expert warned they should be using "INorganic cat litter", which they already were. What a member of the group heard was "AN organic cat litter". The two look very different in print, but when spoken, they're often indistinguishable to a non-chemist. When the discussion made its way to memos and emails, the die was cast.

Evolved 9y ago
They may be indistinguishable but common sense still applies when asking for clarification. For example, I work with folks of a certain intellect where I have to ask very specific and pointed questions that do not contain substantial detail in each question in order to clarify something or to get an answer I need. When that conversation happened, it should have ended with, "just to clarify, I should, or should not, use organic cat litter?" That would have cleared it up. Furthermore, “It would have been much clearer if they had said an inorganic zeolite sorbent,” Hobbs says. Wouldn't one argue that a better way to explain it would be to specify nonorganic kitty litter since that would clear up any confusion whether written or spoken?
- nkurz 9y ago
  Wouldn't one argue that a better way to explain it would be to specify nonorganic kitty litter since that would clear up any confusion whether written or spoken? I don't know. Spoken, "a nonorganic" doesn't strike me as clearly better than "an inorganic" at differentiating from "an organic". Perhaps if you knew in advance the qualififications of the intended recipient, but in a safety specification like this, you may not know much about who will be (mis)interpreting the directive. Specifying "an inorganic zeolite sorbent" in the context of nuclear waste may make it more likely that someone who isn't sure about the meaning of one of those terms will seek clarification. By contrast, I'd worry that specifying "nonorganic kitty litter" would increase the chances that someone will just ignore the essential qualifier. Worse, the word "organic" is overloaded, and means different things to the general public than to chemists. Juxtaposing the chemical meaning with the vernacular "kitty litter" increases the likelihood that someone will misinterpret, especially when "nonorganic" is more commonly associated with marketing and "inorganic" with chemistry. In cases like this where a seemingly innocuous detail is actually of critical importance, it needs to be emphasis and redundancy. The oft-quoted rule of "omit needless words" is more applicable to fiction and journalism than to safety specifications. For something as crucially important as this, I probably would suggest something like "a chemically inorganic sorbent, such as a 'kitty litter' made from zeolite clay".
- everybodyknows 9y ago
  Just such a linguistic difficulty seems to have played out with "flammable". I remember seeing until a few years back gasoline trucks labeled "INFLAMMABLE". No more.
- kevhito 9y ago
  How about not sending a non-expert to the grocery store with a post-it note for supplies when packaging radioactive material for long-term storage. Besides, "organic" when in the grocery store means something completely different any way -- ironically, the organic (wheat-based) product could easily be "non-organic" (meaning not certified to avoid certain pesticides, fertilizers, etc.), while the non-organic (clay-based) product might be labeled "organic" (meaning no pesticides). Really, how about having a specific written signoff procedure in place, where all supplies must be checked before purchase by a trained expert who knows the difference between organic and inorganic / clay vs wheat, signed off in writing against a checklist developed by experts, then checked again by a separate trained expert when delivered with another signoff, then checked again by a third export when actually used.
  - jschwartzi 9y ago
    We could call this process "receiving inspection" and have dedicated staff who perform this inspection who follow some type of written "work instruction" to inspect the receipt before approval.
  - DanBC 9y ago
    > how about having a specific written signoff procedure in place, where all supplies must be checked before purchase by a trained expert who knows the difference between organic and inorganic / clay vs wheat, signed off in writing against a checklist developed by experts, then checked again by a separate trained expert when delivered with another signoff, then checked again by a third export when actually used. Multiple inspection is a known failure point. A thinks any errors they make will be caught by B and C. B thinks A knows what s/he's doing, and thinks any errors that slip by B will be caught by C. C thinks A and B know what they're doing and so no errors will have reached C. The boss that recruited A, B, and C to their position pulled the most accurate workers from the shop floor - because you need the inspectors to be better than the shop floor. Thus quality of product supplied to inspection is reduced; the inspectors are now very busy; and that leads them to shift product through (someone else will catch it; someone else has already caught the problems). What you need is to give an accurate instruction, and to give people to halt if they're unclear what's meant.
- nathanvanfleet 9y ago
  It seems so obvious to us, especially in hindsight. But I reject the notion that it's so obvious "anyone" would question something like this. If an expert says something directly and you are quite sure they said X and not Y, you are not likely to question it. You heard it from the horses mouth. I think that the speaker should try and emphasize INorganic or say it in a clearer way "non-organic" just to drive the point home.
  - dunmalg 9y ago
    >the speaker should try and emphasize INorganic or say it in a clearer way The root problem here is that while the speaker may have been an expert in handling nuclear materials, they were not ALSO an expert in communication. The failure was the presumption that an expert can clearly communicate their domain knowledge across an expertise gap. Communication is a skill unto itself, one that often gets handwaved. People just assume they're good communicators because they can assemble a grammatically correct sentence. My wife is an editor. If I had a nickel for every time she's come home with a story about yet another coworker who claimed they "already edited their own paper and it just needs a quick look-over" and then handed her an incomprehensible mess, I'd have a lot of nickels.
- elipsey 9y ago
  >> a better way to explain it would be to specify nonorganic Exactly. Also, it turns out flammable and inflammable mean the same thing -- I sure learned that one the hard way!
- pmarreck 9y ago
  I don't think it's a good assumption that someone who hears "inorganic" or "an organic" would automatically consider the other.
lowbloodsugar 9y ago
How is "kitty litter" even a reasonable specification at all? We're dealing with nuclear waste but with less rigor than my car mechanic putting the right oil in my car?
- jlewis7272 9y ago
  You've not ever owned a cat have you?
- qbrass 9y ago
  The company that makes Oil Dri doesn't make Nuclear Waste Dri.
- kobeya 9y ago
  This is addressed in the article.
inopinatus 9y ago
Well, then, perhaps the key problem here is that the people charged with packaging nuclear waste were not experts in packaging nuclear waste. For some reason I'm reminded of a recent visit to Takashimaya, a department store in Tokyo. After making a purchase, the checkout operator asked me (in perfectly clear English, for which she unnecessarily apologised) if I would like it wrapped. I said yes (this was a gift). I was directed down the hall to another desk staffed entirely by a team that had apparently been doing nothing for the last eighty years but perfect the art of swiftly and flawlessly packaging objects in attractive wrapping paper. edit: watch here https://www.youtube.com/watch?v=b6ltgrxioeQ https://www.youtube.com/watch?v=b6ltgrxioeQ I have a feeling there are lessons here for the packaging of software, both from the nuclear waste story and the Japanese gift wrap.
- pavement 9y ago
  Thing is, no one I've met ever expects to spend eight decades of their life mastering wrapping paper and little else. In fact, many people might consider that a prison sentence and a slow death. Some jobs are menial, unattractive, dead-end slots in machines designed to squeeze the youth from you. Motivation and morale matter, and maybe some people are cut out to find their niche early, but many are so painfully not. So what to do about that?
  - inopinatus 9y ago
    I didn't necessarily mean that the individual team members had all been there for eighty years. More that the team, as a general entity, had evidently persisted for a long time and built up enormous collective competence at a very specific task, but still in the context of an organic larger entity where their role was appreciated and understood. I think it is a very unhealthy point of view to expect that a single individual perform a single mundane task repetitively and nothing else; sadly it is a common pathology of organisations that many such small roles are used to assemble a larger system. I'm reminded of an extreme case of this every time I traverse a US airport, where there always appear to be far more staff than necessary (especially compared to the majority of airports I transit in Asia, Europe and Oceania) but none of them can assist you with any other part of the system they comprise, leading to many small systemic failures that leave inexperienced travellers confused, late, lost, even detained; and occasional large systemic failures like those recently in the press. This is also how many organisations develop software, particularly enterprises & government, and is a partial explanation for the resulting shitshow. As for what to do about lost potential, I think the answer is the same it ever was: universal education, universal healthcare, eradication of poverty, eradication of conflict, and this a great way to annoy the Randites.
BurningFrog 9y ago
I keep being unsure if people say "can do" or "can't do". They're mostly pronounced the same, so you have to infer from tone and body language. It hasn't caused any major problem for me yet, but I expect that day will come.
squarefoot 9y ago
It's very easy to fall into this mistake because language-wise they're both sorta correct. Using a,an,in etc to prefix a word X to indicate the lack of X is called Alpha Privative which dates back to the ancient Greeks but was later adopted by other cultures. So "inorganic" and "anorganic" might be both correct when expressing the lack of organic material, although as a word "inorganic" is the one that caught up and using "anorganic" - especially in an English speaking context - can lead to misinterpretations like that one.
rebootthesystem 9y ago
All they had to say is "use this SKU kitty litter ONLY, nothing else. Here's the link. Do not buy anything else or you can cause a massive disaster. Here's a picture of the bag. Any deviation from this must be approved by a domain expert." In other words, when failure is not an option you have to engineer out failure vectors. This was stupid simple to prevent. I don't see it as a failure of the workers, they don't know any better. As an example, in aerospace you vet and qualify every single material through Material's Engineers. Only materials that have been approved for a particular use are designed into an assembly. It would be inconceivable for an assembly technician to order an alternative adhesive from a random catalog. This is proper engineering. It sounds like the folks running the nuclear waste installation had no idea how to manage a mission critical process.

Evolved 9y ago

They may be indistinguishable but common sense still applies when asking for clarification. For example, I work with folks of a certain intellect where I have to ask very specific and pointed questions that do not contain substantial detail in each question in order to clarify something or to get an answer I need. When that conversation happened, it should have ended with, "just to clarify, I should, or should not, use organic cat litter?" That would have cleared it up. Furthermore, “It would have been much clearer if they had said an inorganic zeolite sorbent,” Hobbs says. Wouldn't one argue that a better way to explain it would be to specify nonorganic kitty litter since that would clear up any confusion whether written or spoken?

nkurz 9y ago
Wouldn't one argue that a better way to explain it would be to specify nonorganic kitty litter since that would clear up any confusion whether written or spoken? I don't know. Spoken, "a nonorganic" doesn't strike me as clearly better than "an inorganic" at differentiating from "an organic". Perhaps if you knew in advance the qualififications of the intended recipient, but in a safety specification like this, you may not know much about who will be (mis)interpreting the directive. Specifying "an inorganic zeolite sorbent" in the context of nuclear waste may make it more likely that someone who isn't sure about the meaning of one of those terms will seek clarification. By contrast, I'd worry that specifying "nonorganic kitty litter" would increase the chances that someone will just ignore the essential qualifier. Worse, the word "organic" is overloaded, and means different things to the general public than to chemists. Juxtaposing the chemical meaning with the vernacular "kitty litter" increases the likelihood that someone will misinterpret, especially when "nonorganic" is more commonly associated with marketing and "inorganic" with chemistry. In cases like this where a seemingly innocuous detail is actually of critical importance, it needs to be emphasis and redundancy. The oft-quoted rule of "omit needless words" is more applicable to fiction and journalism than to safety specifications. For something as crucially important as this, I probably would suggest something like "a chemically inorganic sorbent, such as a 'kitty litter' made from zeolite clay".
everybodyknows 9y ago
Just such a linguistic difficulty seems to have played out with "flammable". I remember seeing until a few years back gasoline trucks labeled "INFLAMMABLE". No more.
kevhito 9y ago
How about not sending a non-expert to the grocery store with a post-it note for supplies when packaging radioactive material for long-term storage. Besides, "organic" when in the grocery store means something completely different any way -- ironically, the organic (wheat-based) product could easily be "non-organic" (meaning not certified to avoid certain pesticides, fertilizers, etc.), while the non-organic (clay-based) product might be labeled "organic" (meaning no pesticides). Really, how about having a specific written signoff procedure in place, where all supplies must be checked before purchase by a trained expert who knows the difference between organic and inorganic / clay vs wheat, signed off in writing against a checklist developed by experts, then checked again by a separate trained expert when delivered with another signoff, then checked again by a third export when actually used.
- jschwartzi 9y ago
  We could call this process "receiving inspection" and have dedicated staff who perform this inspection who follow some type of written "work instruction" to inspect the receipt before approval.
- DanBC 9y ago
  > how about having a specific written signoff procedure in place, where all supplies must be checked before purchase by a trained expert who knows the difference between organic and inorganic / clay vs wheat, signed off in writing against a checklist developed by experts, then checked again by a separate trained expert when delivered with another signoff, then checked again by a third export when actually used. Multiple inspection is a known failure point. A thinks any errors they make will be caught by B and C. B thinks A knows what s/he's doing, and thinks any errors that slip by B will be caught by C. C thinks A and B know what they're doing and so no errors will have reached C. The boss that recruited A, B, and C to their position pulled the most accurate workers from the shop floor - because you need the inspectors to be better than the shop floor. Thus quality of product supplied to inspection is reduced; the inspectors are now very busy; and that leads them to shift product through (someone else will catch it; someone else has already caught the problems). What you need is to give an accurate instruction, and to give people to halt if they're unclear what's meant.
nathanvanfleet 9y ago
It seems so obvious to us, especially in hindsight. But I reject the notion that it's so obvious "anyone" would question something like this. If an expert says something directly and you are quite sure they said X and not Y, you are not likely to question it. You heard it from the horses mouth. I think that the speaker should try and emphasize INorganic or say it in a clearer way "non-organic" just to drive the point home.
- dunmalg 9y ago
  >the speaker should try and emphasize INorganic or say it in a clearer way The root problem here is that while the speaker may have been an expert in handling nuclear materials, they were not ALSO an expert in communication. The failure was the presumption that an expert can clearly communicate their domain knowledge across an expertise gap. Communication is a skill unto itself, one that often gets handwaved. People just assume they're good communicators because they can assemble a grammatically correct sentence. My wife is an editor. If I had a nickel for every time she's come home with a story about yet another coworker who claimed they "already edited their own paper and it just needs a quick look-over" and then handed her an incomprehensible mess, I'd have a lot of nickels.
elipsey 9y ago
>> a better way to explain it would be to specify nonorganic Exactly. Also, it turns out flammable and inflammable mean the same thing -- I sure learned that one the hard way!
pmarreck 9y ago
I don't think it's a good assumption that someone who hears "inorganic" or "an organic" would automatically consider the other.

lowbloodsugar 9y ago

How is "kitty litter" even a reasonable specification at all? We're dealing with nuclear waste but with less rigor than my car mechanic putting the right oil in my car?

jlewis7272 9y ago
You've not ever owned a cat have you?
qbrass 9y ago
The company that makes Oil Dri doesn't make Nuclear Waste Dri.
kobeya 9y ago
This is addressed in the article.

inopinatus 9y ago

Well, then, perhaps the key problem here is that the people charged with packaging nuclear waste were not experts in packaging nuclear waste. For some reason I'm reminded of a recent visit to Takashimaya, a department store in Tokyo. After making a purchase, the checkout operator asked me (in perfectly clear English, for which she unnecessarily apologised) if I would like it wrapped. I said yes (this was a gift). I was directed down the hall to another desk staffed entirely by a team that had apparently been doing nothing for the last eighty years but perfect the art of swiftly and flawlessly packaging objects in attractive wrapping paper. edit: watch here https://www.youtube.com/watch?v=b6ltgrxioeQ https://www.youtube.com/watch?v=b6ltgrxioeQ I have a feeling there are lessons here for the packaging of software, both from the nuclear waste story and the Japanese gift wrap.

pavement 9y ago
Thing is, no one I've met ever expects to spend eight decades of their life mastering wrapping paper and little else. In fact, many people might consider that a prison sentence and a slow death. Some jobs are menial, unattractive, dead-end slots in machines designed to squeeze the youth from you. Motivation and morale matter, and maybe some people are cut out to find their niche early, but many are so painfully not. So what to do about that?
- inopinatus 9y ago
  I didn't necessarily mean that the individual team members had all been there for eighty years. More that the team, as a general entity, had evidently persisted for a long time and built up enormous collective competence at a very specific task, but still in the context of an organic larger entity where their role was appreciated and understood. I think it is a very unhealthy point of view to expect that a single individual perform a single mundane task repetitively and nothing else; sadly it is a common pathology of organisations that many such small roles are used to assemble a larger system. I'm reminded of an extreme case of this every time I traverse a US airport, where there always appear to be far more staff than necessary (especially compared to the majority of airports I transit in Asia, Europe and Oceania) but none of them can assist you with any other part of the system they comprise, leading to many small systemic failures that leave inexperienced travellers confused, late, lost, even detained; and occasional large systemic failures like those recently in the press. This is also how many organisations develop software, particularly enterprises & government, and is a partial explanation for the resulting shitshow. As for what to do about lost potential, I think the answer is the same it ever was: universal education, universal healthcare, eradication of poverty, eradication of conflict, and this a great way to annoy the Randites.

BurningFrog 9y ago

I keep being unsure if people say "can do" or "can't do". They're mostly pronounced the same, so you have to infer from tone and body language. It hasn't caused any major problem for me yet, but I expect that day will come.

squarefoot 9y ago

It's very easy to fall into this mistake because language-wise they're both sorta correct. Using a,an,in etc to prefix a word X to indicate the lack of X is called Alpha Privative which dates back to the ancient Greeks but was later adopted by other cultures. So "inorganic" and "anorganic" might be both correct when expressing the lack of organic material, although as a word "inorganic" is the one that caught up and using "anorganic" - especially in an English speaking context - can lead to misinterpretations like that one.

rebootthesystem 9y ago

All they had to say is "use this SKU kitty litter ONLY, nothing else. Here's the link. Do not buy anything else or you can cause a massive disaster. Here's a picture of the bag. Any deviation from this must be approved by a domain expert." In other words, when failure is not an option you have to engineer out failure vectors. This was stupid simple to prevent. I don't see it as a failure of the workers, they don't know any better. As an example, in aerospace you vet and qualify every single material through Material's Engineers. Only materials that have been approved for a particular use are designed into an assembly. It would be inconceivable for an assembly technician to order an alternative adhesive from a random catalog. This is proper engineering. It sounds like the folks running the nuclear waste installation had no idea how to manage a mission critical process.