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#747 - Controlling Technologies -- Part 1: The Importance Of Surprises, 10-Jul-2002

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

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

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

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.


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

[2] Jean McSorley, LIVING IN THE SHADOW (London: Pan Books, 1990;
ISBN 0330313312).