Re: [SystemSafety] USAF Nuclear Accidents prior to 1967

From: Andrew Rae < >
Date: Sun, 22 Sep 2013 15:33:10 +0100


I don't think the article suggests that the North Carolina incident was unknown - the "new" information appears to be the specific quotes about the safety switches. From past revelations of this sort, I expect the 700 incidents will turn out to be seven hundred records in a recording system which includes
numerous handling errors, stubbed toes, incorrectly filled-out forms, and a few already widely discussed items of general safety concern.

I'm cautious about reading too much into the nuclear weapons safety record. The big weakness of HROs as a theory is that it selects organisations based on how bad
 their safety record "would have been". This sort of counter-factual reasoning ties my brain in knows - "we should look at what HROs are doing because they are safer than we would expect them to be based on what they are doing ... I mean based on what they are doing except for those bits that make them safe ... you know, they are doing some dangerous things which we shouldn't copy but some things that make it safe anyway that we should copy, and we know which is which because it fits with our preconceived notions of what people should do to be safe".

I think that the nuclear weapons engineering community has likely done a lot of things right, and a lot of things poorly. Unfortunately we don't have enough data to use empirical methods to determine which is which. I've got my fingers crossed we never get that data ...

[No, I'm not a fan of HROs or Normal Accidents. I don't think it's a sociologist thing though - I have a lot of time for the work of Barry Turner, Nick Pidgeon and John Downer. Maybe the trick is to spend just enough time around engineers to understand how we think, without spending so much time that you start to think in exactly the same ways.]

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On 22 September 2013 14:22, Nancy Leveson <leveson.nancy8_at_xxxxxx

> Sorry, I didn't read the Guardian article because I'd heard about the
> North Caroline incident 20 years ago and thought it was public knowledge as
> it is widely talked about in public forums. I'm not sure who it is secret
> from as everyone I know in the nuclear safety world knows about it. I went
> back and read the Guardian article about some "700" incidents. It will be
> interesting to find out what the author of the book is referring to. It is
> hard for me to believe there have been 700 incidents that nobody knows
> about, but perhaps the DoD is better at keeping these things quiet than
> they are about other supposedly secret incidents.
>
> Nancy
>
>
> On Sun, Sep 22, 2013 at 9:02 AM, Dick Selwood <dick_at_xxxxxx >
>> Nancy said "The fact that there was one near miss (and note that it was
>> a miss) with nuclear weapons safety in the past 60+ years is an astounding
>> achievement."
>>
>> The article in the Guardian that Peter cites makes it clear that there
>> were several near-misses
>>
>> d
>>
>>
>>
>>
>> On 22/09/2013 10:53, Peter Bernard Ladkin wrote:
>>
>> While we're indulging in second thoughts....
>>
>> On 9/21/13 8:10 PM, Nancy Leveson wrote:
>>
>> I'm not really sure why people are using an incident that happened 54
>> years ago when engineering was
>> very different in order to make points about engineered systems today.
>>
>>
>> John Downer pointed out on the ProcEng list yesterday evening that
>> Schlosser also wrote an article for the Guardian a week ago in which he
>> pointed out the relevance of his historical discoveries for the present,
>> namely concerning the UK Trident deterrent.
>>
>>
>> http://www.theguardian.com/world/2013/sep/14/nuclear-weapons-accident-waiting-to-happen
>>
>> So he seems to think it is currently relevant.
>>
>> For those who don't know, Trident is a US nuclear multiple-warhead
>> missile carried on British-built and UK MoD-operated submarines, one of
>> whom is always at sea. The maintenance and docking base is in Scotland, at
>> Faslane on the West Coast. Scotland is to vote on independence from GB
>> (which will become LB if so) next year, and the putative government has
>> said it will close the base at Faslane. Further, the Trident "so-called
>> British so-called independent so-called deterrent" (Harold Wilson)
>> replacement will cost untold amounts of money (we have been told, but no
>> one quite believes what we have been told :-) ). Many senior politicians
>> and a large proportion of the concerned public think that money would not
>> so be well spent.
>>
>> It is obviously relevant to all these deliberations to assess how
>> dangerous the old kit really is. Given recent events which have shown US
>> and UK government agencies concerned with national security in a light
>> which has resulted in many citizens losing their trust, I would think any
>> technical assessment such as this, independent of government agencies, of
>> matters relevant to renewing or revoking Trident is a welcome contribution
>> to the debate.
>>
>> PBL
>>
>> Prof. Peter Bernard Ladkin, Faculty of Technology, University of
>> Bielefeld, 33594 Bielefeld, Germany
>> Tel+msg +49 (0)521 880 7319 www.rvs.uni-bielefeld.de
>>
>>
>>
>>
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>
>
> --
> Prof. Nancy Leveson
> Aeronautics and Astronautics and Engineering Systems
> MIT, Room 33-334
> 77 Massachusetts Ave.
> Cambridge, MA 02142
>
> Telephone: 617-258-0505
> Email: leveson_at_xxxxxx > URL: http://sunnyday.mit.edu
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systemsafety_at_xxxxxx Received on Sun Sep 22 2013 - 16:33:22 CEST

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