Can’t Learn from Mistakes

We can’t learn from our mistakes.

Not for Nuclear Power Generation

When it comes to nuclear power plants we can’t learn from our mistakes.  Such lessons are too expensive in terms of injury and property loss.  At least 80,000 people near Fukushima, Japan have been evacuated from their homes perhaps never to return.  At least 4000 cancer deaths are estimated from the Chernobyl, Ukraine accident  (Some respected authorities say it’s 10 times that.) The old saw “we learn from our mistakes” is just that: old fashioned and no longer appropriate to the exposures from such power and risk.   The risk justifies research into the newest Risk Management (RM) protocols and upsetting accepted practices of regulatory RM.

We can never rest.  The job of RM is this instance is never done.  The risks are too great. Some unknowns will always exist so continuous improvement is essential including evaluation of RM theories to advance the understanding of risk and reduce reliance of improving RM by learning from mistakes.

Learning from Mistakes is Outdated

Learning from mistakes worked in the past but doesn’t work anymore.  Modern concepts of RM date back 4 decades and have developed primarily by learning from mistakes.  This old method of development is now evolving into a much more advanced industrial and human factors science that includes theories for quantifying the impact of low frequency high severity events.  This new science is suited for the NPG industry.

Address the Risks of the Enterprise

NPG presents a unique and specialized technology subgroup of risks.  The understanding of risk for this subgroup is well advanced and will always be an integral part of the enterprise Risk Management.  Learning from mistakes regarding this subgroup may be appropriate where computer models illustrate consequences and mitigation protocols.  The best NPG RM will utilize multiple theories of Enterprise RM integrating, centralizing and managing all aspects of RM.

The irony for Fukushima is that many of the mistakes were not technology ones or new mistakes.  Instead they were long ago identified practices of poor risk management: out dated emergency communication plan, critical backup systems without fail safes (example: petroleum fueled emergency generators susceptible to water interruption), inadequate plan for emergency response coordination to name a few.  When performed correctly these proven practices are part of Risk Management that have been in development for decades for all industry not just the NPG industry.

Think Local Act Global

NPG is not a regional RM challenge.  It’s a global problem.  Proof is in the reports of California residents thousands of miles away seeking potassium iodide to manage their radiation risk.  Further evidence is in the interruption of US auto manufacturers parts logistics distribution channels and countries that have restricted the import of food from the Fukushima area.

This is a worldwide challenge so it rests with the worldwide Risk Management profession to seek solutions.

Existing country based governing agencies will likely need to be reorganized and re-tasked with the mission of continuous research and implementation of the newest, best and proven RM protocols.  This includes focus on all of the Human Factors Risk.  One that has been largely overlooked is the risk of the regulators becoming captive to the industry.  This is moral hazard in RM nomenclature.  It is widely believed this moral hazard contributed to the Gulf of Mexico Oil drilling catastrophe and the question is being investigated for Fukushima. Modern RM theorists are beginning to quantify and develop such moral hazard mitigation protocols.

Explore New Theories

There are many great individual thinkers and enterprises focused on RM today not yet addressing these issues in a structured and integrated way.

Here are few US examples. (There are many more outside the US):

RM thinkers: Authors Nassim Nicholas Taleb and Peter Bernstein are just two of the many.  Taleb has written several, the best known and one of his early books is “The Black Swan:  The Impact of the Highly Improbable.”  Bernstein authored “Against the Gods: the Remarkable Story of Risk.”

RM technology: ABSG Consulting has Eqecat’s “catastrophy risk modeling vulnerability functions” which might be the leader.   Verisk Analytics has AIR Worldwide which some consider the first in the modeling industry to have a high degree of confidence.

RM enterprises of higher learning: Berkeley’s Center for Risk Management and Wharton’s Risk Management and Decision Processes Center include researchers and practitioners who recognize the need for interdisciplinary solutions to avoid and mitigate catastrophy.

The above books, risk management institutions and modeling software companies either didn’t exist or were in “start up” at the time of Chernobyl.  So it is a natural and useful evolution to begin their focus on the NPG exposure.

Theory to Explore – Black Swan

A Google search of Taleb and Risk results in 1000’s of pages of references to intellectual discussions of his Black Swan theories.  He has recently written on the dangers of relying on small probabilities as the Japanese Nuclear Commission has done.  His kind of intellectual capital might have great affect on the NPG industry.

Local High Risk – Indian Point, NY

Though NPG is a global issue we can also consider a local issue: the similarities of Fukushima and Indian Point.  There is no debate about the following commonalities: both are close to major population centers, near tidal water exposures and geologic faults and operated by 2 of the world’s most advanced economies,    (Chernobyl raised the question: Is an advanced economy necessary for high quality RM?  The answer may not matter, as it seems catastrophes cross economic boundaries as well as country borders).

If ranking were done based on risk exposure Indian Point would rank very high perhaps projecting the most catastrophic man made accident ever.

Worldwide focus on solutions

NPG is the most dangerous manufacturing activity known to man.  It’s time to focus all that we have learned to date about manufacturing risk and all of the worlds RM intellectual capital on a worldwide effort to properly manage the risk.

Is nuclear power generation essential to our way of life on the planet?  Until that question is settled we must operate on the premise that mankind is up to the challenge and should work on a better approach to managing the risk.

The cost of over reliance on crisis management and learning from mistakes is too high.  Modern Risk Management is a measure of risk and return, that is; how much does one invest of X dollars to reduce the risk Y percent.  These are judgments the RM profession is getting better at all the time. The cost of risk for NPG justifies a campaign equivalent to reducing world hunger, controlling nuclear weapons and mitigating climate change.

There are important and advanced disciplines around the world that can be integrated to assure that available intellectual capital are not wasted in silos separated by distance, culture and economics.


Here’s another irony – managing the risk of NPG has much simpler solutions than any of the other world challenges mentioned above and our way of life may depend on finding the solutions, particularly the way of life for those living near an NPG.