by Russell Targ

Accidents are rarely accidental. Paradoxically, there is almost always one person who could have spoken up courageously and prevented a catastrophe. This article explores why they didn't do that. The tragic and avoidable accidents from recent history, that I describe here, are the result of various combinations of cost-cutting for profit, risk-taking for fame, or ignorance of the complexities of modern systems.

In his wonderful book The Black Swan, Nissam Taleb vigorously points out that leaders and planners tend to underestimate and neglect the potentially devastating calamities that can occur as the result of highly improbable events until they finally do occur. Today we are seeing the entire country of Japan brought to its knees because some planner didn't take account of the possible occurrence of giant tsunami waves that do occur, but less often than once in a century. Anyone who has lived as long as I have has learned to create an internal "payoff matrix" before he leaps to the next great opportunity. This is a statistical tool that is useful in keeping you alive. You estimate "what is the worse thing and the best thing that could happen" in this situation. And then multiply each by the probably of its occurrence. For example, the upside might be an unbelievably exotic and romantic adventure with a new and desirable partner! And the downside might be the remote possibility of AIDS. The analyst learns to avoid attractive opportunities like this, in which the payoff matrix contains a +++ in one of the squares, and a "minus-infinity" (death) in the other square -- even if the probability is really pretty small. If the payoff is national destruction and calamity, we don't build the nuclear power plant eighteen feet above high-tide, even though the twenty-foot tsunami comes only once a century. And above all. We don't put the back-up generator in the basement!

The story I present here is about a world of calamitous accidents, all of which could have been avoided. They represent a grisly and unnecessary loss of life in addition to the loss of many billions of dollars. Perhaps you recall that, before he resigned -- under pressure -- George W. Bush's Attorney General Alberto Gonzales told Congress that "mistakes were made" in the firing of U.S. Attorneys. Senator John McCain used the same locution in describing the conduct of the war in Iraq. The idea that "mistakes were made and lies were told" is a popular distancing device-a Nixon-era political contrivance to indicate that something went terribly wrong, but "It wasn't me. I didn't do it." (This last quotation appears on tee-shirts available from your local bail bondsman.) In the tragedies I will describe here, the mistakes and the lies belong to the rich and powerful. The dismaying result is that none of the perpetrators went to prison-which differs from the case of the bondsman's usual customer, who tends to be poor and disenfranchised.

I am well aware of the problems faced by men and women in the trenches, who see something going wrong, but cannot get a hearing for their concerns. Karen Silkwood at the Kerr-McGee nuclear plant comes to mind. You will remember that she was mysteriously murdered as she was on her way to a press conference to talk about negligence at the nuclear plant. So this is serious business.

As a physicist with a professional career spanning forty-five years in research, development, production and aerospace, I am aware of the dangers in high-level undertakings. I began work as a researcher and pioneer in the development of the laser in the late 1950s -- recruited out of graduate school at Columbia University to work on the exciting laser project while it was still unfolding in the mind of Gordon Gould, its creator. In my last industrial job, I was a project manager standing on the tarmac at Kennedy Space Center measuring the winds along the space shuttle's trajectory -- using a high-power laser system I developed with my team at Lockheed Missiles & Space. So this is a high-risk world I understand. Since 1962 I have ridden my motorcycle through the foothills and potholes of Silicon Valley, while working for Sylvania, Lockheed and Stanford Research Institute.

There is a category of mishaps called "normal accidents," in which a tightly-coupled complex system experiences multiple unexpected component failures. The initial phases of the catastrophic failure of Three Mile Island nuclear power plant was of this type. It wasn't until the operators made some bad decisions that the situation became hopeless. In the end, even with clueless operators, a total meltdown was avoided. With modern technology and massive redundancy, these types of accidents are mercifully rare. In aerospace we have an expression that I have heard many times, "We can make the system foolproof. But we can't make it damn-fool proof." For example, if a modern airplane's electrical or hydraulic system fails, the backup systems will usually come to the rescue even for such a major systems breakdown. However, if the pilot is intoxicated, or has a stewardess on his lap (as in one of our examples), the situation is usually beyond repair. I hear you saying, "A thing like that could never happen." But we are talking here about world-class accidents that did in fact occur. They require world-class stupidity or arrogance for their occurrence. (Just think, if Monica Lewinsky had chosen to have her now famous blue dress dry-cleaned to remove all traces of the president's DNA, the forty-third President of the United States would have been Al Gore instead of George W. Bush, and the world would be a vastly different place than it is today -- no war in Iraq, etc.)

I will briefly summarize the ten cases I have chosen to present, illustrating the extent to which greed and ignorance are sufficient to bring down even the largest edifice or most foolproof contraption. It does not require an earthquake nor a bolt of lightning.

Icebergs and Arrogance: One of the most famous disasters of our time is the 1912 sinking of the ocean liner Titanic during a moonless midnight race to set a trans-Atlantic speed record. The ship roared at its top speed through the icebergs of the North Atlantic, while other nearby ships waited for sunrise to reveal the iceberg hazards. Meanwhile, six warnings were received by the Titanic's radio operator, but the captain was too busy entertaining high society passengers to get the message. The ship struck the iceberg just before midnight, with the loss of fifteen-hundred lives in the freezing water. The calamity was exacerbated by the fact that the ship had only the minimum allowable number of lifeboats, to allow dancing on the top (lifeboat) deck! (Interestingly, the entire event was foretold fourteen years earlier by Morgan Robertson's 1898 book The Wreck of the Titan, Or Futility. Robertson, an American writer, correctly prophesied the length, displacement, number of waterproof compartments and ultimate fate of the then unconceived and unbuilt ship.)

Molasses in January: To my mind the most bizarre of the calamities fitting my greed and ignorance model is the great two-million gallon Boston Molasses Catastrophe of 1919. The fifty-foot high, ninety foot diameter tank filled with molasses was designed by Mr. Arthur Jell, the chief accountant of the U.S. Industrial Alcohol Company (USIA), and built in one of Boston's most crowded slums. There was no building inspection conducted, because the Boston building department was convinced that this enormous structure shouldn't be considered a building. Its continual leakage of molasses from all its plates was dealt with by a coat of molasses-colored paint. Finally, in a rush for one more shipment of molasses to the rum makers before Prohibition became the law of the land, the tank was filled to capacity. Although there is nothing as slow as molasses in January, the tank collapsed at noon, flooding the streets of Boston's North End with a twenty foot wave of sticky, gooey death -- killing twenty, injuring more than a hundred, and taking down the elevated railroad tracks. After six years of litigation, USIA was found guilty of negligence and fined $600.000, equivalent to about $30 million today.

Silkwood: The nuclear melt-down movie The China Syndrome was released just before the accident at the Three Mile Island nuclear power plant, which occurred at 4AM, on March 31, 1979. The Karen Silkwood case is one of the sources for the movie. Silkwood had discovered evidence of falsified quality control data at the Kerr-McGee plant near Crescent, Oklahoma where she worked as a technician, and like Hector in the movie, she fell victim to a supposed accident as someone rammed her car off the road from behind while she was on her way to deliver the evidence to the press. I saw the film the day before the accident. And when I heard of the disaster on the radio the next morning, I though it was a movie trailer. (These things always happen on the graveyard shift -- in the industry there is a phenomenon known as "wide awake at 3AM," after a book of the same name.) The near melt-down of this 850-megawatt power reactor outside Harrisburg, Pennsylvania was contained by the thick steel containment vessel (unlike Chernobyl). The reactor spontaneously shut itself down ("scrammed") in response to spurious internal signals -- which also disastrously shut down the cooling water pumps. Many books, and tens of thousands of pages of findings have been written on this immensely complicated accident which released 43,000 curies of radioactive krypton into the atmosphere -- luckily with no fatalities. From my point of view, the principle cause of the accident was not the inappropriate action of the two sleepy operators who closed off the cooling water when they should have opened it up. It was that they simply didn't know how to respond to two pressure gauges giving contradictory readings. In my opinion they just guessed wrong, although the President's Report blames them. The other contributing factor in play here was a major cost-cutting operation to reduce maintenance costs by Metropolitan Edison, who was the owner and operator of the plant. For unknown reasons the two large valves that control the back-up cooling water had been manually closed two days before the accident, and evidently nobody noticed! If the valves had been properly inspected and opened there would have been no calamity, even with the accidental shut down. Obviously, the technicians operating the system could also have been better trained. As with most accidents, there were numerous factors-and numerous mistakes. Unfortunately, reactor operators save lots of money by eliminating inspections. But here we are thirty years later.

New York Times, May 8, 2011

NUCLEAR AGENCY BESET BY LAPSES

Critics Say Watchdog Is Too Close To Industry

In the fall of 2007, workers at the Byron nuclear power plant in Illinois (just outside Chicago) were using a wire brush to clean a badly corroded steel pipe-one in a series that circulate cooling water to essential emergency equipment -- when something unexpected happened: the brush poked through. The resulting leak caused a 12-day shutdown of the two reactors for repairs. The plant's owner, the Exelon Corporation, had long known that corrosion was thinning most of these pipes. But rather than fix them, it repeatedly lowered the minimum thickness it deemed safe. By the time the pipe broke, Exelon had declared that pipe walls just three-hundredths of an inch thick -- less than one-tenth the original minimum thickness -- would be good enough. [This is also not an "accident."]

Pass the Vodka: Several years after Three-Mile Island, on April 26, 1986, at 1:30 AM reactor number four at the Chernobyl power plant in the northern Ukraine exploded releasing into the midnight air four-hundred times more radiation than the atomic bomb dropped on Hiroshima. It would require the resettlement of more than 300,000 people, and is thought to have caused 4000 additional cancer deaths. The explosion blew the 2000-ton concrete top off the intensely hot reactor, spreading debris over hundreds of miles-because there was no containment vessel of any kind for the reactor! (Who needs a expensive steel containment for a well tested reactor?) A safety test had been planned for the reactor the previous day, but it could not be concluded before the next shift. To briefly summarize the Chernobyl Reactor disaster: Late that night two technicians decided to do the safety test themselves, which involved carefully reducing the cooling water to the reactor -- always a delicate operation. Next, one must even more carefully withdraw two of the control rods while monitoring the reactor power. (Incidentally, this reactor was three times the size of Three Mile Island-several gigawatts.) As the two techs huddled over the still-surviving scribbled notes that had been left for them, the reactor violently spiked in energy and heated up so exponentially that the control rods could not be pushed back into place. Thus the core overheated, melted and went critical. Once again, wide awake at 3AM -- this time at 1:30AM. We know the tragic end. (In my experience, over several years in various Russian labs, nothing happened without a couple glasses of vodka-although that doesn't usually appear in the accident report.)

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