“Is this really the way it all works? An uninformed arbitrary decision.... made by some apparatchik?” Valery Legasov
“Is there anything more frightening than people?” Svetlana Alexievich, Voices from Chernobyl: The Oral History of a Nuclear Disaster
The Chernobyl disaster was a nuclear accident that occurred on Saturday 26 April 1986, at the No. 4 nuclear reactor in the Chernobyl Nuclear Power Plant, near the city of Pripyat in the north of the Ukrainian SSR. It is considered the worst nuclear disaster in history.
Why did the plant explode? Management was viewing their job through the wrong frame.
First, the technical issues (sourced through Wikipedia). A detailed investigation identified that reactor design flaws and breach of protocol during simulated power outage safety test. The specific findings were as follows:
1) The plant was not designed to safety standards in effect and incorporated unsafe features
2) Inadequate safety analysis" was performed
3) There was insufficient attention to independent safety review
4) Operating procedures not founded satisfactorily in safety analysis
5) Safety information not adequately and effectively communicated between operators, and between operators and designers
6) The operators did not adequately understand safety aspects of the plant
7) Operators did not sufficiently respect formal requirements of operational and test procedures
8) The regulatory regime was insufficient to effectively counter pressures for production
9) There was a general lack of safety culture in nuclear matters at the national level as well as locally
Finally, the reactor rods that were designed to slow down the nuclear reaction actually increased initial output!
The frame should have been safe power production. The actual frame was to satisfy the demands of the “state”!
The former Soviet Union was a large enterprise, and like any large organization it had its own ecosystem with several distinguishing characteristics. The first was an absolute requirement to be loyal to the state, and that loyalty was demonstrated by doing what you where told when you were told to do it. Dissension and dissent were ruthlessly rooted out and eliminated. Positions were achieved by who you knew and your ability to curry favor with powerful people, not based on technical merit. Finally, there was a culture of secrecy and deniability.
If you are thinking “Wow, I’ve worked in organizations like that!”, you probably have.
You have a poorly designed, poorly maintained, poorly built nuclear reactor. You have poorly trained employees who most likely got their jobs through politics and whose primary goal was to satisfy the orders of their boss. You have a culture of conformance, not a culture of safety.
With the management having the wrong frame, this outcome was sadly predictable.
What frame does your organization have? Does your organization demand conformance, or can you challenge the wrong frame?
It matters.
Coda
As I am finishing typing this US President Donald Trump is discussing the governments preparation for a potential Coronavirus pandemic. China has quarantined over 50 million people, Japan has suspended public schools and the president has asked all state and local authorities to review their emergency preparedness plans. The stock market has dropped 10% wiping out trillions in wealth. This sounds like something to worry about! On January 27, while we were being told everything was fine, I published an article stating that my frame was telling me things were going to get much worse. I was right. What did your frame tell you?