THE IMPORTANCE OF SURPRISES

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ontrolling Technologies--Part 1

THE IMPORTANCE OF SURPRISES

 

The scientists who first split the atom, in 1942, were no doubt

some of the smartest people in the world: Enrico Fermi, J. Robert

Oppenheimer, Hans Bethe, Neils Bohr, Glenn Seaborg, and dozens of

others. For the next 50 years, nuclear technology served as a

magnet for brainy people, attracting graduate students who were

excited to work at the cutting edge of technology where research

funds were nearly limitless. In the field of nuclear weapons,

nuclear power or nuclear medicine, if you had a bright idea, you

could probably find the funds to explore it, so smart people

flocked into nuclear technology.

 

Despite all this brain power, in 60 short years nuclear

technology has created an array of problems that now rank among

the most difficult, dangerous and long-lived that the world has

ever faced, and which grow larger each passing year. What went

wrong?

 

This is an important question because -- despite all the problems

it has already created -- the nuclear industry is redoubling its

efforts to expand. [NY TIMES May 7, 2001, pg. A17] Furthermore,

nuclear is not the most complex technology humans have set out to

master: biotechnology and the now-emerging nanotechnology[1] are

intrinsically much more complex. (Nanotechnology is the attempt

to create molecule-sized machines, some of which can themselves

create more molecule-sized machines.) If we are having trouble

controlling nuclear technology, shouldn't we think twice before

deploying new technologies that are far more complicated, much

less understandable and therefore far less predictable?

 

What went wrong with nuclear? The people who gave us nuclear

technology evidently didn't notice that our ability to control

complex systems is limited by surprises that arise from three

sources: (1) technical misunderstanding of the underlying

chemistry, physics, or biology; (2) an astonishing range of

management lapses (including simple errors, unwillingness to

confront the troublesome parts of a problem, a tendency to doze

off on the job after a few uneventful years, and the human desire

to hide and deny embarrassing mistakes); and (3) the shifting

sands of politics and economic dislocations, including commercial

competition.

 

The history of nuclear power tells us that these three kinds of

surprises (technical, managerial, and political) set pretty

narrow limits on the human capacity to control complex

technologies. Nuclear technology has clearly exceeded our human

capacity for control, while biotech and nanotech make nuclear

seem simple and easy by comparison.

 

Where is the evidence that nuclear is uncontrollably complex?

It's in the newspapers almost every week. Let's take a look.

 

** Because it operates 51 nuclear power plants to generate

electricity, Japan justifiably ranks high among the high-tech

nations. However, on Sept. 30, 1999, an atomic fuel plant in the

town of Tokaimura, 87 miles northwest of Tokyo, spewed

radioactivity into the air. At least 35 workers were exposed and

300,000 nearby residents were told to shut their windows and stay

indoors. [NY TIMES October 1, 1999, pgs. A1, A10.] When the

accident occurred, the Tokaimura plant was in its 17th year of

commercial operation.

 

The accident began when workers poured 35 pounds of uranium --

instead of the usual 5 pounds -- into a tank containing nitric

acid. (Management surprise.) The tank happened to be surrounded

by a shell filled with water, which reflected neutrons back

toward the uranium, thus promoting a chain reaction. (Technical

surprise.) There was an ominous blue flash of light as the 35

pounds of uranium " went critical, " meaning a nuclear chain

reaction had begun spewing deadly gamma rays and neutrons into

the surrounding area.

 

Japanese nuclear safety officials had previously scrutinized the

plant and concluded that an accidental chain reaction was

impossible, so the plant had no emergency plan. (Management

surprise.) [NY TIMES Oct. 23, 1999, pg. A4.]

 

It took Japanese authorities 17 hours to bring the atomic

reaction under control. The Tokyo Electric Power Company rushed

880 pounds of sodium borate to the plant to absorb radiation and

quench the nuclear reaction, but they discovered they had no way

of getting close enough to the chain reaction to dump the powder

onto it. (Management surprise).

 

Japanese authorities requested help from the U.S. military

stationed in Japan but were told those troops were not equipped

to deal with nuclear accidents. (Management surprise.) [NY TIMES

October 1, 1999, pgs. A1, A10.]

 

Workers finally brought the chain reaction under control by

smashing a pipe connected to the water shell, letting the water

drain out. [NY TIMES Oct. 23, 1999, pg. A4.]

 

The Japanese Government Nuclear Safety Commission immediately

blamed the workers involved. One member of the Commission said,

" If they had done their job as they were supposed to, there is no

way something like this could have happened. " [NY TIMES Oct. 1,

1999, pg. A10.]

 

However, a few days later it became apparent that the Government

Nuclear Safety Commission had misunderstood the situation.

(Management surprise.) The NEW YORK TIMES reported that, for

years, the plant's managers had been pressuring workers to skip

important safety steps, to increase productivity and improve

competitiveness. One of the injured workers said he had routinely

used procedural shortcuts following directions given in an

illegally-drafted plant manual that allowed workers to speed up

production. [NY TIMES Oct. 4, 1999, pg. A8.] For their part,

plant managers continued to blame the workers' " lack of

sufficient expertise, " as if employee training were not a

management responsibility. (Management surprise.) Plant managers

refused to acknowledge that they had urged workers to speed up

production, " But company officials have acknowledged that the

plant had recently faced intense foreign competition, " the NEW

YORK TIMES reported. (Management surprise, political surprise.)

 

The most highly-irradiated worker in the September accident,

Hisashi Ouchi, 35, died of his injuries December 22. The Japanese

government had made heroic efforts to keep him alive, transfusing

10 pints of fresh blood into his body each day for several months

before his death. Just as the government feared, his death

catalyzed a citizen movement to oppose the expansion of nuclear

power in Japan, and especially to stop the use of MOX, or " mixed

oxide fuel. " (Political surprise.) [NY TIMES Jan. 13, 2000, pg.

A1.] MOX fuel combines plutonium with uranium into fuel for

nuclear power plants, as a way of (1) avoiding the need for new

uranium fuel; and (2) in some cases, reducing the world's supply

of pure plutonium, 18 pounds of which can be used to make a crude

but effective A-bomb. [NY TIMES November 12, 2001, pg. B1.]

 

Japan had been planning to purchase mixed oxide fuels (MOX) from

a British plant known as Sellafield, an industrial complex on the

edge of the Irish Sea employing 10,000 workers. Sellafield had

begun operating a nuclear power plant in 1956, but the plant

caught fire Oct. 10, 1957, exposing workers and nearby residents

to excessive radioactivity. (Technical surprise.) In 1957, the

British government denied anyone had been harmed but in 1983 the

British National Radiological Protection Board estimated that the

doses received by the public during the 1957 fire could cause

hundreds of thyroid cancers.[2] (Technical surprise, management

surprise.) The British government released its health report in

1988, 31 years after the fire, and some of the health data remain

secret to this day. (Management surprise.)

 

Sellafield survived the disaster of 1957 and went on to expand

its operation to include nuclear fuel reprocessing and nuclear

waste management. In anticipation of a growing market for MOX

fuels, Sellafield invested $480 million in a new fuel fabrication

facility in 1999. Japan agreed to buy 1/3 of the plant's output.

 

Unfortunately, shortly after Sellafield shipped its first batch

of MOX fuel to Japan, British authorities discovered that

Sellafield workers had falsified inspection documents related to

the fuel rods sent to Japan. (Management surprise.) A union

representative blamed commercial competition: " Clearly there was

commercial pressure to meet customers' demands, " he said.

(Political surprise.) [NY TIMES Apr. 20, 2000, pg. C4.]

 

In Japan, news of the falsified inspection documents created such

an uproar that the fuel was rejected and shipped back to

Sellafield. [NY TIMES Jan. 13, 2000, pg. A1.] Switzerland and

Sweden then suspended shipments of spent fuel to Sellafield.

(Political surprise.)

 

Germany, too, said it had received MOX fuels from Sellafield

accompanied by falsified documents. Subsequently Germany raised

concerns about " irregularities " in MOX fuel manufactured at La

Hague in France, engulfing the entire MOX fuel industry in

scandal and controversy. (Management surprise, political

surprise.) [NY TIMES April 20, 2000, pg. C1.] Two months later,

Germany announced that it would phase out and shut down all 19 of

its nuclear power plants. (Political surprise.) [NY TIMES June

16, 2000, pg. A6.]

 

But Sellafield's troubles did not stop there. Two months after

the revelation of falsified documents, British government

inspectors reported " systematic management failures " at the

Sellafield complex and found fault with Sellafield's entire

" safety culture. " (Management surprise.) [NY TIMES April 20,

2000, pg. C4.] Shortly after this embarrassing revelation,

British authorities announced that " a saboteur had severed cables

controlling robotic operations in a radioactive area of the

installation. " (Management surprise.) [NY TIMES March 27, 2000,

pg. A8.] Ireland and Denmark then began an international campaign

to have the Sellafield plant closed for good. (Political

surprise.)

 

With its MOX fuel investment in serious trouble and its

reputation in tatters, Sellafield announced that recent events

had forced it to increase the price for cleaning up the Hanford

Nuclear Reservation in Washington state, USA, one of the most

contaminated places on Earth, where DuPont, Westinghouse and

other private firms made plutonium for weapons between 1943 and

1987. In October 1998, Sellafield has offered to solidify -- for

a fee of $6.6 billion\- -- 54 million gallons of DuPont's and

Westinghouse's discarded radioactive liquids, sludges and salts

held in 177 tanks at Hanford. But 18 months later, in late April

2000, Sellafield management said the Hanford cleanup would now

cost U.S. taxpayers $15.2 billion. The U.S. Department of Energy

balked, canceled the contract with Sellafield and declared its

attempt to " privatize " the Hanford cleanup a failure. Evidently,

the private sector can affordably create one of the world's

largest radioactive stews but cannot affordably clean it up.

(Management surprise, political surprise.) [NY TIMES April 27,

2000, pg. C4; NY TIMES May 9, 2000, pg. C4.]

 

The Hanford cleanup is itself a technical frontier. Of the 177

waste tanks at Hanford, 149 are made of a single shell of steel.

So far, 68 tanks have leaked and " all the single-shell tanks are

expected to leak eventually, " the NY TIMES reported March 23,

1998, pg. A10. (Technical surprise.)

 

For 50 years, private-sector and governmental managers at the

Hanford Reservation steadfastly maintained that leaks of

radioactive liquids were inconsequential because the soil would

bind the radioactive particles tightly, preventing them from

moving into the Columbia River. However, in 1997 officials

announced that they had been wrong and that leaked wastes had

already entered the river. (Technical surprise.) [NY TIMES Oct.

11, 1997, pg. A7.]

 

Of the 54 million gallons of wastes abandoned by DuPont and

Westinghouse at Hanford, so far at least 900,000 gallons have

escaped into the soil on their way to the river. No one has any

idea how to retrieve them. (Technical surprise.) [NY TIMES Mar.

23, 1998, pg. A10.]

 

To be continued.

 

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[1] http://www.foresight.org/NanoRev/FIFAQ1.html#FAQ1 and

http://www.nanozine.com/WHATNANO.HTM#whatsa

 

[2] Jean McSorley, LIVING IN THE SHADOW (London: Pan Books, 1990;

ISBN 0330313312).