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Who Destroyed Three Mile Island?

Who Destroyed Three Mile Island?

(as presented at RailsConf 2018)

Nickolas Means

April 17, 2018
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  1. Who Destroyed Nickolas Means @nmeans

  2. Who Destroyed Nickolas Means @nmeans

  3. @nmeans

  4. @nmeans • #WhoDestroyedTMI @nmeans

  5. @nmeans

  6. @nmeans

  7. @nmeans

  8. @nmeans

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  10. @nmeans

  11. @nmeans

  12. @nmeans

  13. Three Mile Island Nuclear Generating Station Londonderry Township, Pennsylvania @nmeans

  14. Three Mile Island Harrisburg, Pennsylvania @nmeans • #WhoDestroyedTMI @nmeans TMI

    Unit 2 906 MWe Babcock and Wilcox PWR
  15. @nmeans Bill Zewe Fred Schiemann Ed Frederick Craig Faust

  16. Condensate Polishers @nmeans

  17. Three Mile Island Unit 2 @nmeans

  18. Three Mile Island Unit 2 @nmeans

  19. Three Mile Island Unit 2 @nmeans

  20. Three Mile Island Unit 2 @nmeans

  21. Three Mile Island Unit 2 @nmeans

  22. Three Mile Island Unit 2 @nmeans ❌

  23. Three Mile Island Unit 2 @nmeans ❌

  24. Three Mile Island Unit 2 @nmeans ❌

  25. @nmeans TMI Unit 2 Control Room

  26. Three Mile Island Unit 2 Three Mile Island Unit 2

    @nmeans
  27. Pressurizer @nmeans Connection to Primary Cooling Loop Heating Element Water

    Spray 1. Regulates System Pressure 2. Measures Water Level 3. Absorbs Pressure Shocks
  28. Three Mile Island Unit 2 Three Mile Island Unit 2

    @nmeans
  29. Three Mile Island Unit 2 Three Mile Island Unit 2

    @nmeans
  30. Three Mile Island Unit 2 @nmeans

  31. Three Mile Island Unit 2 @nmeans

  32. @nmeans

  33. Three Mile Island Unit 2 @nmeans

  34. Three Mile Island Unit 2 Three Mile Island Unit 2

    @nmeans
  35. @nmeans

  36. Three Mile Island Unit 2 Three Mile Island Unit 2

    @nmeans
  37. @nmeans

  38. Three Mile Island Unit 2 Three Mile Island Unit 2

    @nmeans
  39. Three Mile Island Unit 2 Three Mile Island Unit 2

    @nmeans
  40. Three Mile Island Unit 2 @nmeans

  41. @nmeans

  42. Three Mile Island Unit 2 @nmeans ❌ ❌

  43. @nmeans

  44. Fuel Rod Assembly @nmeans

  45. Gary Miller George Kunder @nmeans

  46. Three Mile Island Unit 2 @nmeans ❌

  47. Three Mile Island Unit 2 @nmeans ❌ ❌ ❌

  48. @nmeans

  49. @nmeans

  50. @nmeans

  51. Final Core State @nmeans

  52. @nmeans

  53. Three Mile Island Today @nmeans

  54. @nmeans

  55. @nmeans

  56. @nmeans Hindsight Bias

  57. @nmeans Outcome Bias

  58. @nmeans

  59. Three Mile Island Unit 2 @nmeans

  60. Three Mile Island Unit 2 @nmeans

  61. Pressurizer @nmeans Connection to Primary Cooling Loop Heating Element Water

    Spray 1. Maintains System Pressure 2. Measures Water Level 3. Absorbs Pressure Shocks
  62. @nmeans

  63. Heat at 100% 12 MWth 2,841 MWth Heat at Shutdown

    (6.5%) 0.78 MWth 185 MWth @nmeans
  64. Three Mile Island Unit 2 @nmeans

  65. Three Mile Island Unit 2 Three Mile Island Unit 2

    @nmeans
  66. @nmeans

  67. Three Mile Island Unit 2 @nmeans • #WhoDestroyedTMI Three Mile

    Island Unit 2 @nmeans
  68. @nmeans

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  70. @nmeans

  71. @nmeans

  72. @nmeans Human error is never the cause.

  73. @nmeans Ask what is responsible, not who.

  74. @nmeans Understand why it made sense.

  75. @nmeans Seek forward accountability, not backward.

  76. @nmeans Always look for the second story.

  77. Who Destroyed Nickolas Means @nmeans

  78. Who What Destroyed Nickolas Means @nmeans

  79. @nmeans

  80. @nmeans

  81. Who What Destroyed Nickolas Means @nmeans