Upgrade to Pro — share decks privately, control downloads, hide ads and more …

Who Destroyed Three Mile Island?

Who Destroyed Three Mile Island?

(as presented at RailsConf 2018)

Nickolas Means

April 17, 2018
Tweet

More Decks by Nickolas Means

Other Decks in Programming

Transcript

  1. Who Destroyed
    Nickolas Means
    @nmeans

    View Slide

  2. Who Destroyed
    Nickolas Means
    @nmeans

    View Slide

  3. @nmeans

    View Slide

  4. @nmeans • #WhoDestroyedTMI
    @nmeans

    View Slide

  5. @nmeans

    View Slide

  6. @nmeans

    View Slide

  7. @nmeans

    View Slide

  8. @nmeans

    View Slide

  9. @nmeans

    View Slide

  10. @nmeans

    View Slide

  11. @nmeans

    View Slide

  12. @nmeans

    View Slide

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

    View Slide

  14. Three Mile Island
    Harrisburg, Pennsylvania
    @nmeans • #WhoDestroyedTMI
    @nmeans
    TMI Unit 2
    906 MWe
    Babcock and Wilcox PWR

    View Slide

  15. @nmeans
    Bill Zewe
    Fred Schiemann
    Ed Frederick
    Craig Faust

    View Slide

  16. Condensate Polishers
    @nmeans

    View Slide

  17. Three Mile Island Unit 2
    @nmeans

    View Slide

  18. Three Mile Island Unit 2
    @nmeans

    View Slide

  19. Three Mile Island Unit 2
    @nmeans

    View Slide

  20. Three Mile Island Unit 2
    @nmeans

    View Slide

  21. Three Mile Island Unit 2
    @nmeans

    View Slide

  22. Three Mile Island Unit 2
    @nmeans

    View Slide

  23. Three Mile Island Unit 2
    @nmeans

    View Slide

  24. Three Mile Island Unit 2
    @nmeans

    View Slide

  25. @nmeans
    TMI Unit 2 Control Room

    View Slide

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

    View Slide

  27. Pressurizer
    @nmeans
    Connection to Primary
    Cooling Loop
    Heating Element
    Water Spray
    1. Regulates System Pressure
    2. Measures Water Level
    3. Absorbs Pressure Shocks

    View Slide

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

    View Slide

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

    View Slide

  30. Three Mile Island Unit 2
    @nmeans

    View Slide

  31. Three Mile Island Unit 2
    @nmeans

    View Slide

  32. @nmeans

    View Slide

  33. Three Mile Island Unit 2
    @nmeans

    View Slide

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

    View Slide

  35. @nmeans

    View Slide

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

    View Slide

  37. @nmeans

    View Slide

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

    View Slide

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

    View Slide

  40. Three Mile Island Unit 2
    @nmeans

    View Slide

  41. @nmeans

    View Slide

  42. Three Mile Island Unit 2
    @nmeans


    View Slide

  43. @nmeans

    View Slide

  44. Fuel Rod Assembly
    @nmeans

    View Slide

  45. Gary Miller
    George Kunder
    @nmeans

    View Slide

  46. Three Mile Island Unit 2
    @nmeans

    View Slide

  47. Three Mile Island Unit 2
    @nmeans



    View Slide

  48. @nmeans

    View Slide

  49. @nmeans

    View Slide

  50. @nmeans

    View Slide

  51. Final Core State
    @nmeans

    View Slide

  52. @nmeans

    View Slide

  53. Three Mile Island Today
    @nmeans

    View Slide

  54. @nmeans

    View Slide

  55. @nmeans

    View Slide

  56. @nmeans
    Hindsight Bias

    View Slide

  57. @nmeans
    Outcome Bias

    View Slide

  58. @nmeans

    View Slide

  59. Three Mile Island Unit 2
    @nmeans

    View Slide

  60. Three Mile Island Unit 2
    @nmeans

    View Slide

  61. Pressurizer
    @nmeans
    Connection to Primary
    Cooling Loop
    Heating Element
    Water Spray
    1. Maintains System Pressure
    2. Measures Water Level
    3. Absorbs Pressure Shocks

    View Slide

  62. @nmeans

    View Slide

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

    (6.5%)
    0.78 MWth 185 MWth
    @nmeans

    View Slide

  64. Three Mile Island Unit 2
    @nmeans

    View Slide

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

    View Slide

  66. @nmeans

    View Slide

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

    View Slide

  68. @nmeans

    View Slide

  69. @nmeans

    View Slide

  70. @nmeans

    View Slide

  71. @nmeans

    View Slide

  72. @nmeans
    Human error is never the cause.

    View Slide

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

    View Slide

  74. @nmeans
    Understand why it made sense.

    View Slide

  75. @nmeans
    Seek forward accountability,
    not backward.

    View Slide

  76. @nmeans
    Always look for the second story.

    View Slide

  77. Who Destroyed
    Nickolas Means
    @nmeans

    View Slide

  78. Who What Destroyed
    Nickolas Means
    @nmeans

    View Slide

  79. @nmeans

    View Slide

  80. @nmeans

    View Slide

  81. Who What Destroyed
    Nickolas Means
    @nmeans

    View Slide