175 Times. And then the Catastrophe.

[prfesser]

From 2007. I was thinking that this might belong in the Research forum, but figured that it applies to anyone who does something that is apparently hazardous, with the argument "I've done it dozens of times" or "Hold my beer and watch this!" or "I saw it on YouTube, it must be okay". Eventually a concatenation of errors may catch up to you.

Abstract: Company runs industrial-sized preparation 175 times without incident. And then...
https://corante.com/safety-warnings/175-times-and-then-the-catastrophe/
Be careful, and be aware. Always.

PS: by the same author, on a lighter note; you don't need to know much chemistry to laugh heartily at this one: https://blogs.sciencemag.org/pipeli...3/things_i_wont_work_with_dioxygen_difluoride (AKA FOOF, appropriately enough)

Best -- Terry

 

[NateB]

That is a good read. From the way it is written, that crew apparently didn't fully understand the risks of the reaction they were working with and got lucky 175 times. Maybe they got complacent with their success or maybe they did not identify when the reaction went bad?

We spend sobering time reviewing accidents within our industry. They are rarely purely mechanical problems and usually involve a sequence of human errors rather than a single fatal mistake.

There is the lingering question when working with energetic materials if it is safer to mix 1 large batch than multiple small batches.

 

[jqavins]

Maybe they got complacent with their success...

As I've often said, complacency kills. But it sounds to me more like the engineers who designed the reactor were the complacent ones. Lack of redundancy in the cooling system seems like the biggest part of the cause, though there are certainly other factors. (There are always more than one factor, as you noted.) In such a system, there should not only be redundancy, but coolant flow sensors that tell you when the there's a problem with the primary system (and the backup has been automatically switched in) so that with the backup running there's time to shut the reaction down.

I'm an engineer working on passenger train brake systems. I have a fake motivational poster in my cubical, one I made for myself. It shows the Challenger explosion and the caption reads "Complacency - What will you tell the widows?" I wouldn't want to be the engineer who signed off on that reactor design and meets the families of those killed.

 

[rfjustin]

Along these same lines, I recall Jim Jarvis posting a while back about documenting "near miss" scenarios. Also a great read!