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I'm submitting this based on the current top item "North Dakota law lists fake critical minerals based on coal lawyers' names" [0]. This accident was traced to

I'm submitting this based on the current top item "North Dakota law lists fake critical minerals based on coal lawyers' names" [0]. This accident was traced to a manager transcribing "inorganic absorbent" as "an organic absorbent". A more serious example of the need to have competent people with domain knowledge in the room and empowered when documents are written. [0] https://news.ycombinator.com/item?id=46492161 https://news.ycombinator.com/item?id=46492161

daymanstep 9mo ago
I'm surprised they made critical material purchasing decisions based on what some guy thinks he heard in a meeting, rather than official written documents written by and cross-checked by multiple engineers.
- GuB-42 9mo ago
  There is almost never a single cause, here there was 12, it is often called the swiss cheese model. The root cause is a bad transcription, which probably happened many times, but for some reason, this time, all the safeguards failed. It happens sometimes, with catastrophic results. Hopefully, procedures will be adjusted, but in general, you can only minimize risks, not prevent catastrophic events entirely. It was an expensive mistake, but thankfully, no one died.
- 12_throw_away 9mo ago
  > I'm surprised they made critical material purchasing decisions based on what some guy thinks he heard in a meeting Right? We don't store nuclear waste where I work ... BUT one time we needed to buy a bunch of ethernet cables, basically the same thing. We wrote down our requirements, came up with some options. The engineers evaluated the options before purchasing and checked what we received before installing it. There wasn't even a formal process, it's just ... how you do your job? Obviously organizational dysfunction is a real thing, particularly at LANL, so I can definitely imagine how this sort of thing can fall through the cracks for various processes. But I feel like but requirements verification should be a rigorously enforced formal procedure before storing nuclear waste in perpetuity.
  - jrjeksjd8d 9mo ago
    The difference is that in a large organization the people documenting the procedure, the people doing the procurement, the people receiving the order and the people packing the drums are all different people. Potentially in different buildings. You can't expect the original scientist who wrote the white paper based on experiments in a glovebox to be present every time they pack waste into drums.
    - pixl97 9mo ago
      Oh and it gets even worse when there are bean counters at the end of the procurement chain.
- TheGrassyKnoll 9mo ago
  Reminds me of the Starboard/Larboard nautical terminology. That must have created many disasters over the years. It took the British navy hundreds of years to rectify that one.
cperciva 9mo ago
Not just when documents are written, but also when the practices they describe are implemented. You don't need to know a lot of chemistry to realize that mixing organics with nitric acid is a bad idea. Why did none of the technicians doing the work say "hold on, this doesn't seem right"?
- bloomingeek 9mo ago
  My guess, they were afraid to ruffle the feathers of their higher-ups. Yes, that's moronic, but this is the world we can find ourselves in IF the bosses are egotistical kingdom makers.
  - cperciva 9mo ago
    Right, people need to feel empowered and not just worried about ruffling feathers.
    - PaulHoule 9mo ago
      The second accident here https://en.wikipedia.org/wiki/Tokaimura_nuclear_accidents https://en.wikipedia.org/wiki/Tokaimura_nuclear_accidents was an example of where that "empowerment" went wrong. It is usual for workers in Japanese factories to make continuous improvements in process for quality and cost and it is usually a good thing... but criticality accidents involve invisible dangers and "following procedures strictly" in that kind of work saves lives. Notably Japan has been the world leader in nuclear accidents since the 1980s and some of that is that they kept working on things like fast reactors after many other countries quit and others that are cultural. For instance at American BWR reactors it is routine to test the isolation condenser whenever the reactor is shut down so everybody knew what it sounded like (LOUD!) when it worked but when somebody at Fukushima was asked if it was working they saw a little steam coming out the ports but had never seen it work before and didn't know what to expect.
      - cperciva 9mo ago
        Let me rephrase that. People need to feel empowered to stop a potentially dangerous process. They definitely shouldn't be empowered to implement new dangerous processes without external review.
formerly_proven 9mo ago
Inflammable means flammable? What a country!
- DoctorOetker 9mo ago
  inflammation of a tissue is when it is rendered inflammable /s
rob74 9mo ago
Thanks for highlighting that, I missed that in the video and was wondering why "anorganic" should be something different than "inorganic" (in my native German it's "anorganisch"). But still, I'm a bit alarmed that a trained nuclear technician would simply follow these instructions and mix organic material with acid without having any second thoughts about it...
- IggleSniggle 9mo ago
  I think it's worth remembering that this was a storage procedure that was also already abnormal/odd because of the specifics of the existing shielding. I think it's somewhat understandable for a technician to trust that the chemists know what they're doing in that kind of circumstance. If they had concerns, they may have even voiced them, but as is often the case, if the authority confirms that even though it's strange it's correct, it's not surprising that a technician would follow the directive. Even the authority figure may have verbally confirmed, "you said an organic absorbent??" "Yes, that's right, inorganic absorbent." Maybe even in a meeting that was meant to clarify written procedures.
dredmorbius 9mo ago
... transcribing "inorganic absorbent" as "an organic absorbent"... A literal, or literary, bit-flip.

daymanstep 9mo ago

I'm surprised they made critical material purchasing decisions based on what some guy thinks he heard in a meeting, rather than official written documents written by and cross-checked by multiple engineers.

GuB-42 9mo ago
There is almost never a single cause, here there was 12, it is often called the swiss cheese model. The root cause is a bad transcription, which probably happened many times, but for some reason, this time, all the safeguards failed. It happens sometimes, with catastrophic results. Hopefully, procedures will be adjusted, but in general, you can only minimize risks, not prevent catastrophic events entirely. It was an expensive mistake, but thankfully, no one died.
12_throw_away 9mo ago
> I'm surprised they made critical material purchasing decisions based on what some guy thinks he heard in a meeting Right? We don't store nuclear waste where I work ... BUT one time we needed to buy a bunch of ethernet cables, basically the same thing. We wrote down our requirements, came up with some options. The engineers evaluated the options before purchasing and checked what we received before installing it. There wasn't even a formal process, it's just ... how you do your job? Obviously organizational dysfunction is a real thing, particularly at LANL, so I can definitely imagine how this sort of thing can fall through the cracks for various processes. But I feel like but requirements verification should be a rigorously enforced formal procedure before storing nuclear waste in perpetuity.
- jrjeksjd8d 9mo ago
  The difference is that in a large organization the people documenting the procedure, the people doing the procurement, the people receiving the order and the people packing the drums are all different people. Potentially in different buildings. You can't expect the original scientist who wrote the white paper based on experiments in a glovebox to be present every time they pack waste into drums.
  - pixl97 9mo ago
    Oh and it gets even worse when there are bean counters at the end of the procurement chain.
TheGrassyKnoll 9mo ago
Reminds me of the Starboard/Larboard nautical terminology. That must have created many disasters over the years. It took the British navy hundreds of years to rectify that one.

cperciva 9mo ago

Not just when documents are written, but also when the practices they describe are implemented. You don't need to know a lot of chemistry to realize that mixing organics with nitric acid is a bad idea. Why did none of the technicians doing the work say "hold on, this doesn't seem right"?

bloomingeek 9mo ago
My guess, they were afraid to ruffle the feathers of their higher-ups. Yes, that's moronic, but this is the world we can find ourselves in IF the bosses are egotistical kingdom makers.
- cperciva 9mo ago
  Right, people need to feel empowered and not just worried about ruffling feathers.
  - PaulHoule 9mo ago
    The second accident here https://en.wikipedia.org/wiki/Tokaimura_nuclear_accidents https://en.wikipedia.org/wiki/Tokaimura_nuclear_accidents was an example of where that "empowerment" went wrong. It is usual for workers in Japanese factories to make continuous improvements in process for quality and cost and it is usually a good thing... but criticality accidents involve invisible dangers and "following procedures strictly" in that kind of work saves lives. Notably Japan has been the world leader in nuclear accidents since the 1980s and some of that is that they kept working on things like fast reactors after many other countries quit and others that are cultural. For instance at American BWR reactors it is routine to test the isolation condenser whenever the reactor is shut down so everybody knew what it sounded like (LOUD!) when it worked but when somebody at Fukushima was asked if it was working they saw a little steam coming out the ports but had never seen it work before and didn't know what to expect.
    - cperciva 9mo ago
      Let me rephrase that. People need to feel empowered to stop a potentially dangerous process. They definitely shouldn't be empowered to implement new dangerous processes without external review.

formerly_proven 9mo ago

Inflammable means flammable? What a country!

DoctorOetker 9mo ago
inflammation of a tissue is when it is rendered inflammable /s

rob74 9mo ago

Thanks for highlighting that, I missed that in the video and was wondering why "anorganic" should be something different than "inorganic" (in my native German it's "anorganisch"). But still, I'm a bit alarmed that a trained nuclear technician would simply follow these instructions and mix organic material with acid without having any second thoughts about it...

IggleSniggle 9mo ago
I think it's worth remembering that this was a storage procedure that was also already abnormal/odd because of the specifics of the existing shielding. I think it's somewhat understandable for a technician to trust that the chemists know what they're doing in that kind of circumstance. If they had concerns, they may have even voiced them, but as is often the case, if the authority confirms that even though it's strange it's correct, it's not surprising that a technician would follow the directive. Even the authority figure may have verbally confirmed, "you said an organic absorbent??" "Yes, that's right, inorganic absorbent." Maybe even in a meeting that was meant to clarify written procedures.

dredmorbius 9mo ago

... transcribing "inorganic absorbent" as "an organic absorbent"... A literal, or literary, bit-flip.