Who Destroyed Three Mile Island? - Nickolas Means | The Lead Developer Austin 2018
LeadDev
Why leaders watch it
Shows why blaming operator error misses the system, interface and training failures behind an accident, a model for postmortems.
Nickolas Means recounts the 1979 Three Mile Island accident minute by minute, from the control rod insertion to the operator's decision to switch off emergency cooling. He argues that finding systemic causes is more useful than blaming individuals.
Takeaways
- Look for system causes before blaming individuals
- Poor design and training set operators up to fail
- Good postmortems reconstruct decisions in context
Topics: Failure, safety & learning orgs, Systems thinking & complexity
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