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Engineering failures and broken organizational culture through analysis of the Chernobyl series (2019)

Alex Shapira illuminates interesting points in the treatment of the Chernobyl disaster, which perhaps attention to in real time could have changed the tragic results

Building the Panama Canal - between history and engineering and a bit about disease eradication, by Alex Shapira

From English Wikipedia, fair use poster, https://he.wikipedia.org/w/index.php?curid=1716268
From English Wikipedia, Fair use of poster

The explosion of reactor 4 of the Chernobyl nuclear power plant was among the largest industrial disasters in history [1]. The event has been studied from many different angles and disciplines, from the physics of nuclear reactors to the psychological meanings of the evacuees from the disaster area. A simple search on Google Scholars brought up over 90,000 scientific papers, as of March 2024. 

The idea of ​​writing about the disaster has been in my head for a long time, both because of the magnitude of the event and because of the great engineering interest. At the same time, after reading excellent articles by Yaniv Tanenbaum Ketan [2] and Uri Teichman [3], I realized that there is enough quality material in Hebrew and there is not much to innovate on the topic of describing the disaster. 

Then she left The Chernobyl series ... 

The shocking series by Craig Mazin, which was released in 2019, won numerous film awards inside and outside the United States [4], "exploded" the Internet in the post-Soviet space for several weeks. As my brother-in-law said (Hi Tolik), what annoyed the Russians the most was that the British were able to show Russian culture better than the Russians were able to show their culture.

In addition to being a great drama series, which perfectly combined stories of personal tragedies of ordinary people and the global event that an entire country had to mobilize in order to handle it, the creators of the series did not shy away from going into the deep technical details and explained very well what happened there physically. 

and Chania Famate

A few words about the last episode of the series, "Vechnia Famiat" (Remembrance to a Witness in Russian). I have seen this episode several times and I really recommend showing it in industrial plant safety workshops. In the center of the episode, the trial of those who were caught as the main ones responsible for the disaster, the deputy chief engineer at the plant, Anatoly Dyatlov, the chief engineer, Nikolai Fomin and the power plant manager, Viktor Bryukhanov, is presented. The climax of the trial scene is of course the testimony of Valery Legasov, the scientific director for handling the consequences of the disaster, who focused on the physical causes of the explosion and ultimately exposed the Soviet regime's culture of lies. At the same time, there were two more testimonies: the testimony of Boris Shcherbina, the director of Chernobyl disaster treatment and Olena Khomyuk, a complex figure representing all the scientists in Legasov's team [4]. 

While Legasov's testimony is complex, requiring a minimal understanding of physics, Cherbina and Khamiuk talk about much more everyday things, understood and known to everyone. 

So Boris Shcherbina mentioned The management's pressure to carry out the safety experiment that ultimately led to the disaster, the pressure that stemmed from personal considerations of the factory's management. Khomiuk mentioned that the preparations for the experiment were not optimal, the experimental procedure was full of misunderstandings and anomalies, in addition due to the instruction from "above" the experiment was moved to the night hours and thus had to be carried out by an inexperienced shift and workers who were not trained for such a complex experiment. 

As someone who immigrated from Ukraine after the fall of the Soviet Union, I would be the last person to defend the communist system, but after all, I am an engineer and Shcherbina and Khumiuk's testimony made me wonder if these (supposedly) secondary causes could occur in any society and country. After all, anyone who has been in the worlds of development and production of large projects, it's true, how many times have you encountered pressure from management to meet deadlines, no matter what, even if it means cutting corners and going through such and such procedures. 

Perhaps unintentionally, Craig Mazin showed in the last episode of the series the different angles of the disaster and the fact that it cannot be approached from one point of view or look for one fateful cause.

The purpose of this work It is still worth checking, how historically reliable is the series in terms of techno-engineering description of the disaster? I actually asked myself questions such as was the team that performed the experiment really untrained as Humiuk claimed? What was the meaning of an inappropriate radiation meter? and more. Naturally, the stories presented here are not the main stories of the series, on the other hand I tried not to analyze specific events in order not to turn the article into a trivia game. (For those wondering, a case of Helicopter crash above the reactor In the second episode, really happened, but happened a few months after the disaster, on October 2, 1986) 

Well, let's start with something not related to engineering..  

Firefighter Vasily Ignatenko

Well, here it's simple - Everything here is real

This story line is taken from the book "Chernobyl Prayer" by Nobel Laureate (2015), Belarusian writer, Svetlana Alekseevich [6]. For the purpose of writing the book, Alekseevich interviewed Ludmila Ignatenko, Vasili's widow, among others, so the truth and authenticity of the story is clear and beyond doubt. I read theספר And I cried in the process (the book is excellent but very difficult and tragic), so I was pleasantly surprised when I saw this story repeated in the series, since I did not feel that this book was famous except for the post-Soviet bloc. Therefore it showed the depth of investigation that its creators had reached.

To summarize this sub-chapter, as of 2020, Lyudmila Agantenko lived in the town of Barzino in central Belarus, together with Vasily's mother and raised a son. 

Let's move on to engineering. 

Experimental procedure 

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As mentioned, in the last episode Olena Khomiuk made two serious claims about the factory's organizational culture. The first claim, as seemingly boring and unimportant as it is, refers to the fact that the procedure for conducting the experiment was unclear and full of inconsistencies. During Khomiuk's reconstruction, they show that some of the lines of the procedure are underlined in red, but when the shift manager, Alexander Akimov, asks colleagues who tried to perform the experiment last time, whether it is required to perform these actions, he receives a positive answer! 

what really happened?

Well... what do you think? 

Well, in general A series tells the truth (I look at the message of the series and don't go into the subtleties, yes it was erased in red or black). Certainly, an experimental procedure was so unclear and ambiguous that the workers (poor people, all but Dyatlov died within a few weeks of radiation sickness) simply ignored it [7]. Undoubtedly, a clear and legible test procedure simplifies the work, but at the same time, it should be noted that during the event the workers violated approximately all existing safety instructions, excluded various safety mechanisms from the activity [3], so I doubt that it was precisely the lack of a good procedure that caused the major disaster . 

Also, I will point out that the safety culture is constantly on the rise. I've been working in the industry with safety aspects for about 18 years and the safety culture of 2006 was nothing like what exists now, and that's a good thing. I "raised" some (well, let's be real, three) friends who worked in the industry in Israel before the 15s and their answer justified what I thought - the safety requirements of that time (let's remember, 20-XNUMX years before the disaster) were much lower than now. So to sum up this issue, the safety requirements are being upgraded which is very good, but unfortunately, many times They were written in blood.

skill and competence of the staff

The Chernobyl disaster did not happen because of one fatal mistake by an engineer or a power plant technician, but because of a series of actions that the operating team performed, actions that they clearly were not allowed to perform [7]. 

series

Again from the Hamiuk testimony: because of an order from Kiev, the execution of the experiment was postponed from daytime hours to the night shift. This instruction came for a completely banal reason: the end of the month was approaching (the original date was April 25), due to the constraints of a planned Soviet economy, all the factories that were customers of the power plant had to meet the production goals that were set for them and therefore could not allow the shutdown of machines [2]. Following this instruction, the experiment was supposed to be carried out by an inexperienced shift and by people who did not understand what they were doing and to what danger they were exposing the reactor, such as, for example, Leonid Toptunov (died on May 14, about three weeks after the disaster), one of the critical staff members and responsible On stabilizing the reactor, he was on duty for a total of two months.

In addition, special attention was given to the conduct of Anatoly Dyatlov, deputy chief engineer of the plant and who was actually responsible for the experiment. The series shows his brutal behavior (there is no other way to define it) towards the staff, he shouts and humiliates the employees, deceives and silences their every question.  

Leonid Toptunov in reality and in the series [8] 

https://www.youtube.com/watch?v=Qxkqg2iF8JE

Anatoly Dyatlov, reality versus the series [9] 

what really happened?

Well, regarding the staff skill question, The issue is quite complex. Toptonov, although he was really only two months in his current position, on the other hand he worked at the power plant for over 3 years [8]. Alexander Akimov (died on May 11), shift supervisor, was already an engineer with 10 years of experience, 7 years of which he worked at the power plant in various positions and for about two years was shift supervisor [10]. Everyone can think as they see fit, for me personally it's hard to call them "new and inexperienced employees". and yet, They didn't understand what they were doingTherefore, we will move on to the second story of this subsection - Dyatlov's behavior. Overall, Everything here is true. Once again, the creators of the series should be praised for the depth of the research they did - they built Dyatlov's character based on the testimonies of his colleagues and employees who worked under him. Well, not everything is known about Dyatlov's conduct that night, one must remember that a significant number of his employees died within a few weeks, Dyatlov himself was under criminal investigation, so it is clear that he was very careful in his testimony, but from what is known - Dyatlov was not an easy person to work with, Although he was very professional, he was also impatient, rude and sometimes humiliated his subordinates. There is evidence that even on the night of the accident he shouted at Akimov and did not let him read the experimental procedure [11]. The reason I dwell on this point is because, in my opinion, this is one of the main reasons for the disaster - Dyatlov's conduct led toBlind obedience and lack of independent thought. Why does a group of experienced and good employees do a rather short series of actions that they were clearly not allowed to do? They should have figured it out. How come none of them stood up and stopped this madness? 

Also, it should be noted, the problem of blind obedience to authority and lack of independent thought existed in the past and still exists now in different societies and cultures. Only in recent years have various companies recognized it as something that requires attention. For example, it was noted as one of the weak points that must be addressed in order to reduce the rate of air accidents of the Korean Airlines company [12]. One can also conclude that in Israel, this problematic phenomenon if it exists then in a much lesser form, here no one will do something without fully understanding why (even after they understand they won't do it, but that's another story). As important as it is, this issue has been identified as one of the main reasons for the boom in Israeli hi-tech [13].

Radiometer 

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The sentence said in the first episode of the series "Not good - Not terrible” became viral and one of the most recognizable in the series.

The staff at Dyatlov's beginning relies on a radiation meter that has gone beyond the limit of its measurement capability and shows the maximum value it can show (in engineering language - the meter has entered saturation) - 3.6 x-rays per hour. From this they draw false conclusions that the reactor is not damaged and work all night under this false assumption. Also, Dyatlov passes on this incorrect information to his managers and only the next day, after losing precious hours, are the dimensions of the disaster revealed.  

what really happened?

here too, in general, All true. I say, in general, because I did not find what the initial level of radiation was measured at the moment of the disaster. The power plant used several types of radioactive radiation meters, dosimeters, [15] most of which were originally designed for the Soviet military and used in nuclear submarines. Indeed a radiation meter relied upon by Dyatlov and his team showed radiation exposure at a rate of 3.6 x-rays per hour. Let's do some math, currently radiation is measured in units of millisieverts where 1 x-ray per hour translates to 10 millisieverts per hour. That is, during the working hours after the explosion, the station employees thought they were exposed to radiation of a few hundred millisieverts. According to the figure below, one can understand Dyatlov: indeed Not good – not terrible. It can be concluded that whoever designed the radiation measurement system at the power plant, really did not think about a scenario of the reactor explosion where the radiation levels are so high that the workers are not allowed to be in this environment for more than a few minutes, as it really was. The gauge was for routine work. 

Back to Dyatlov, his first wrong conclusion was that the reactor was intact and what was damaged was only the cooling system. His second wrong conclusion was andThat's what he did the fate of his team - their exposure to radiation is still low and will manifest itself in mild radiation sickness.

Beyond a political disaster, there was a personal tragedy here - a series tells what really happened, Alexander Akimov and Unid Toptunov after the disaster spent the rest of the night pumping cooling water into the reactor [2], which no longer existed! During this time they were exposed to a tremendous level of radiation that killed them within a few weeks, They sacrificed their lives for an action that had no purpose!! 

Effect of radiation on humans, from [14]
Effect of radiation on humans, from [14]

Effect of radiation on humans, from [14]

In conclusion, write an experimental procedure that is as clear as possible and stick to it, give room for questions and doubts, usually the more preparation there is before a complicated experiment, the more likely it will be successful and you will use gauges that also cover beyond the desired measurement area. 

Health to all. 

This article is in memory of our beloved daughter, the late Michal. miss you

We miss you very much, mom dad June.  

Sources:

[1] The list of the biggest technological disasters in the world Wikipedia

[2] The Chernobyl series on a large, small science website

[3] The worst nuclear accident

[4] Chernobyl series in the English Wikipedia

[5] Chernobyl disaster Wikipedia

[6] Chernobyl Prayer Wikipedia

[7] Chernobyl disaster on the website of the World Nuclear Association

[8] Leonid Toptonov reality vs. series, YouTube

[9] Anatoly Dyatlov, YouTube

[10] Alexander Akimov, Wikipedia

[11] Anatoly Dyatlov, Russian Wikipedia

[12] Excellent: What Success Is Made of, Malcolm Gladwell

[13] Blue and white silver, Uri Katz

[14] Ionizing radiation, Wikipedia

[15] Radiation meters in Chernobyl (Russian)

2 תגובות

  1. You should redo it. Hebrew obliges God to know in many sentences. A well-known problem of immigrants from the USSR/CIS.

    The obvious conclusion is that the workers did not know the dangers; The design of the reactor was defective because it did not include an automatic shutdown; There were no radiation meters everywhere; Management was apathetic.

    It is a fact that other reactors in the world did not have such problems (almost).

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