The world has seen project failures that cost billions of money, but once it saw a failure that cost thousands of people lives, learning its lessons the hard way.
“Measured by the amount of contamination it produced, the Chernobyl explosion was equivalent to more than 10 of the atomic bombs dropped on Hiroshima,” Washington Post reported back in 1992.
Even though the fatal mistakes took place more than thirty years ago, they had an unimaginably strong ripple effect of radionuclides spewing across the large area of Central Europe. Unseen, they are still traveling in time through generations, causing thyroid pathologies, stirring our genes and thoughts.
In 2018, the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) reported that the accident also was responsible for nearly 20,000 documented cases of thyroid cancer among individuals who were under 18 years of age at the time of the accident in the three affected countries including Belarus, Ukraine and the Russian Federation. – NEI, May 2019.
What makes me especially sensitive about this topic is personal experience – being a witness to the consequences of the disaster in Ukraine, knowing people who took an active part in clearing up after the accident happened.
HBO’s miniseries was just another hard punch in the chest. After the final fifth episode, who could rest aside?
The Manager: Causing the World’s Nuclear Disaster
Even though there was a certain hierarchy of managers running the reactor, their ambitions were compatible – either move in the career ladder or retire in due time. To let it happen, both managers had one task unfinished – running a safety test to make sure that the reactor can function properly in the event of power loss at the plant itself.
Except that the timing was wrong.
The major test prerequisite was to reduce a reactor power output to 20% of its operating capacity. The team started the process in the morning, and the reactor output was reduced to 50%. Shortly, the power grid controller from Kyiv instructed the team not to reduce the power output any further. Because it was the end of the month, many industrial production goals had to be met, so they required additional power from RBMK.
As a result, the reactor operated at half capacity for more than 10 hours prior to the test continuation, building up poisonous Xenon inside the core. At this point, after the shift change at midnight, a series of multiple management mistakes took place.
What exactly led to the tragedy? Under the above circumstances, the Manager in charge of the operation committed the following mistakes and ignored the next problems.
1. The night shift was not trained to perform a safety test.
Assigning important tasks to inexperienced people was what happened in that room that night, according to the beholders. A 25-year old trainee was put in charge of reducing the power output with others contemplating and helping him. Dyatlov delegated the outage mission to the team that has never run such safety tests before and headed out of the room where the experiment took place.
Lesson learned: The delegation of safety tasks requires trained individuals and long-term analytical thinking.
2. People were bullied to do the job.
The Manager was reported to threaten his subordinates to turn everyone adrift if they didn’t stick to the pecking order. He used his authoritative position to scare the team into illogical actions. Afraid to lose their jobs, operators didn’t have another choice than to submit, not realizing that had they rebelled, none of the dangers would happen. Five of the dozen people working in the control room got lethal burns caused by radiation and died just a few days after the disaster.
Lesson learned: When there’s a split of second to identify the risks of your future actions, think twice.
3. Elementary safety precautions were ignored.
It is strongly believed that the accident was a cause of a series of human errors combined with failed management. And there are facts to support it. “When Chernobyl’s workers took manual control over the rods, they had pulled most of the 211 control rods out of the reactor. Safety standards at the time required a minimum of 28 rods in the core. The workers only left 18,” reports Vice. Needless to say, security knowledge doesn’t fall outside the remit of any manager’s responsibility. Project managers have their part to play in building security into projects they manage.
Lesson learned: First, safety first. Second, safety first.
4. Personal ambitions have become work priorities.
Placing his interests first, Dyatlov overlooked all of the above. The Manager’s priority #1 was to get higher in the chain of command by any means. Basically, it was the dominance of ambitions that generated the state of indifference to the safety norms and teamwork. Ambitions, in Dyatlov case, led to the improper distribution of responsibilities and delegation of the main tasks to young incompetent operators. Visualizing his promotion, Dyatlov most likely lost a large-scale, long-term picture of the project. In fact, personal ambitions tapered off his intuition and shuttered the balance between work responsibilities and personal needs.
Lesson learned: Never place your own interests and ambitions above the project.
5. A major flaw of the reactor has been hidden from the team.
The AZ-5 button could have stopped it all, had the reactor been built, according to the safety protocols and technologies, able to prevent it from overheating. A design flaw, however, only increased a fatal power surge wildly. In reactors similar to Chernobyl, dozens of rods control the nuclear power being lowered into the reactor core. But in this reactor, the rods were designed differently with the absorbent part located in the middle and graphite tips increasing reactivity. As one of the operators pressed the AZ-5 button and the tip of the rods entered the core, they forced out the water, which caused a small but significant surge of power. In combination with other conditions, this mentioned power increase was sufficient to prompt the explosion.
Lessons learned: Create hypothetical training for your team starting with “What if…” questions that do not require direct actions.
The State: Fatal Senior Management Mistakes
According to Times, Green Peace estimates that up to 900,000 people will die or have died as a result of Chernobyl exposures. It was the major cost of the USSR blindness to problems and risks that might occur as a result of deploying one of RBMK reactors.
‘Why worry about something that isn’t going to happen?’ was the position of the State, indicating the core of the apparatus, pointed by Craig Mazin in the series.
In fact, the State had a lion’s share of guilt in the tragedy, mainly because of the wrong power distribution.
There is real merit to this argument. The lesson of Chernobyl isn’t that modern nuclear power is dangerous. The lesson is that lying, arrogance and suppression of criticism is dangerous.
The flaws that led to Chernobyl are the same flaws shown by climate change deniers today. https://t.co/rBYOX1sl8u
— Craig Mazin (@clmazin) April 8, 2019
The domination of the State power over common sense manifested itself in the following points.
1. A scientific paper has been censored.
The scientific paper, mentioning the design peculiarities of the RBMK reactors has been censored – with the important part presenting the structure of the core of the reactor cut out. But in contrast to the operators of the Chernobyl plant, who were sentenced for their part in the catastrophe, the designers of the reactor managed to get away with their crime. According to the Washington Post, the principal designer, Anatoly Aleksandrov, a past president of the Soviet Academy of Sciences, refused to concede that there had been anything wrong with his reactor. The worst thing was that vital safety information was withheld. Operators have been misinformed about the design of the reactor. Because they thought that the AZ-5 button can stop it all, they only accelerated the tragedy.
2. The level of radiation understated.
“We seal off the city,” Zharkov says. “No one leaves. And cut the phone lines. Contain the spread of misinformation. That is how we keep the people from undermining the fruits of their own labor.”
While the level of radiation was already deadly to people and spotted by the European countries, the State kept the citizens of Pripyat and nearby areas in disinformation to cover up the scale of the disaster. “The official position of the State,” as indicated in the series, “is that a global nuclear catastrophe is not possible in the Soviet Union.”
Communist Party members have never been punished for keeping their secrets.
A Cross-Cutting Project Management Lesson
After all that has been said about the disaster, managers can learn an exceptional lesson. In the most recent article, one of Forbes’ contributors to Leadership Strategy and book author, John Baldoni, stated:
Chernobyl was not a natural disaster; it was a man-made one. When management is inept, mistakes can happen and go uncorrected until the problem becomes severe. Yet while management may fail, it is often the employees – the unsung women and men of the organization – who meet the challenge and correct the problem.
And we’re still there, fighting with the consequences. According to PMI, cleaning up after the worst nuclear accident in history has taken more than 30 years – and a nonstop cluster of high-risk projects. The final phases of remediation in Ukraine, the experts indicate, couldn’t proceed safely until the 10-year, US$1.6 billion New Safe Confinement project was completed.
But the inflection point of it all was years before the accident, somewhere behind the walls soaked with cigarette smoke. The momentous decision to tell lies and keep secrets from everyone. The decision to have a positive outlook in the eyes of the Big West. The Russians didn’t want to take a backseat in the nuclear industries. Any flaws, if detected, would be swept under the red carpet.
The Project has taught us many lessons. The lies become starker with fire. The reactor didn’t care – an object would never obey to the ideology.
Illustration: Copyright © Oksana Drachkovska