What are 5 Lessons from Chernobyl? (#118)
Thirty-five years ago today (April 26, 1986), the #4 RBMK nuclear reactor at the Chernobyl Nuclear Power Plant, near the city of Pripyat in the Ukraine, exploded due to a flawed reactor design, serious mistakes by the plant operators, and a poor safety culture. It is the worst nuclear accident in terms of costs and casualties. The explosion released 5% of the reactor core into the environment and caused the deaths of 30 people due to acute radiation syndrome, over 5,000 cases of thyroid cancer, and the relocation of over 350,000 people. The Soviet Union and later Russia spent 18 billion in Soviet rubles (roughly US$68 Billion today) to encase the reactor in concrete, clean-up the radioactive waste, and decontaminate the environment.
Last year, I got fascinated with the disaster. I read Adam Higginbotham’s amazing book, Midnight in Chernobyl: The Untold Story of the World's Greatest Nuclear Disaster. Check it out on Amazon here and his website here. I watched the HBO miniseries Chernobyl on the disaster. It’s on Amazon Prime for $19.99 and well worth the investment. The photos in today’s post are from several photographers’ recent visits to the Chernobyl Exclusion Zone, a 1,000 square mile zone that is off-limit to human habitation. Tourists are allowed to visit the site for no more than five hours due to the radioactivity.
What are five lessons you can you use with your team that can be drawn from the disaster?
Like most accidents, the Chernobyl disaster started with a small series of shortcuts from established protocol. Are your people following the established protocols? Where are they taking shortcuts?
Designed in the 1960s, the RBMK is a graphite-moderated reactor that produced 1,000 MW of power. In addition to the Chernobyl Nuclear Plant’s 4 RBMK reactors, 13 more of these type of reactors were in use across the Soviet Union when the accident occurred. The RBMK had design flaws that had been exhibited at other plants. However, the lessons learned about the design flaws had not been shared across the Soviet nuclear community. Where have lessons been learned in your organization that haven’t been shared to other like parts of the organization?
The leadership at the Chernobyl Nuclear Power Plant had absolute faith that the reactor wouldn’t explode. Despite evidence, during the initial hours of the accident, they remained unwilling or unable to understand the truth and the scope of the disaster. Their faith slowed the proper reaction to the crisis. How do you, as a leader, revisit your assumptions, especially during a crisis?
During routine operations, dangerous systems, like the Chernobyl Nuclear Power Plant, require standardized procedures, checklists, and centralized control to prevent mistakes. During an accident, however, the operators closest to the system are required to take independent and creative actions to avoid disaster. Most bureaucracies can’t handle the paradox of daily control and independent creativity during accidents. What sort of rehearsals and drills are you using to develop creativity during crisis in your operators? Are your operators empowered to act decisively during a crisis?
It is an important to instill a learning culture into your organization. One way that helps to create this culture is by using the After Action Review. The AAR is a way to install rigor to your post-mortem or debrief while ensuring each member of the team takes responsibility for doing something better next time. See more in Post #41.
Depending on the estimate, it will be anywhere from the year 2341 to the year 5021 when the Chernobyl site will no longer be radioactive.
Go on the offense, apply one or all of the Chernobyl lessons learned to your dangerous/high-risk operations, and keep working the problem.