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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

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  2. Who Destroyed
    Nickolas Means
    @nmeans

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  3. @nmeans • #WhoDestroyedTMI
    @nmeans

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

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

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

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  7. Condensate Polishers
    @nmeans

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  8. Three Mile Island Unit 2
    @nmeans

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  9. Three Mile Island Unit 2
    @nmeans

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  10. Three Mile Island Unit 2
    @nmeans

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  11. Three Mile Island Unit 2
    @nmeans

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  12. Three Mile Island Unit 2
    @nmeans

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  13. Three Mile Island Unit 2
    @nmeans

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  14. Three Mile Island Unit 2
    @nmeans

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  15. Three Mile Island Unit 2
    @nmeans

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  16. @nmeans
    TMI Unit 2 Control Room

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

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

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

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

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  21. Three Mile Island Unit 2
    @nmeans

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  22. Three Mile Island Unit 2
    @nmeans

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  23. Three Mile Island Unit 2
    @nmeans

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

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

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

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

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  28. Three Mile Island Unit 2
    @nmeans

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  29. Three Mile Island Unit 2
    @nmeans


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  30. Fuel Rod Assembly
    @nmeans

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  31. Gary Miller
    George Kunder
    @nmeans

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  32. Three Mile Island Unit 2
    @nmeans

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  33. Three Mile Island Unit 2
    @nmeans



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  34. Final Core State
    @nmeans

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  35. Three Mile Island Today
    @nmeans

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  36. @nmeans
    Hindsight Bias

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  37. @nmeans
    Outcome Bias

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  38. Three Mile Island Unit 2
    @nmeans

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  39. Three Mile Island Unit 2
    @nmeans

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

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

    (6.5%)
    0.78 MWth 185 MWth
    @nmeans

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  42. Three Mile Island Unit 2
    @nmeans

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

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

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  45. @nmeans
    Human error is never the cause.

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

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  47. @nmeans
    Understand why it made sense.

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  48. @nmeans
    Seek forward accountability,
    not backward.

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  49. @nmeans
    Always look for the second story.

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  50. Who Destroyed
    Nickolas Means
    @nmeans

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  51. Who What Destroyed
    Nickolas Means
    @nmeans

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  52. Who What Destroyed
    Nickolas Means
    @nmeans

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