#systemsthinking#threemileisland#blamelesspostmortem
54K subscribers • 4 videos on Hallway
Intermediate. Assumes working knowledge.
762K views8 years ago4 recommendations
Tools and practiceSystems programmingSRE and incidentsCode review and teamworkObservability and monitoring
Nickolas Means reconstructs the Three Mile Island nuclear accident to show how systemic failures and poor interface design, rather than individual operator error, cause disasters.
On March 28, 1979, at exactly 4 o’clock in the morning, control rods slammed into the reactor core of Three Mile Island Unit #2, halting the nuclear reaction because of a fault in the reactor cooling system. At , the automated emergency cooling system activated as the reactor core temperature continued to rise. At , one of the plant operators made the befuddling decision to switch off the emergency cooling system, dooming the reactor to partial meltdown. Why? When something bad happens, it’s easy to just blame someone and move on. Taking the time to find the systemic causes, though, will not only help keep the problem from repeating, it will enable you to build the psychological safety necessary for your team to truly collaborate. Let’s let the story of Three Mile Island teach us how to make our teams stronger through systems thinking and just culture.What people say. Recommended as a classic talk on systems thinking, blameless postmortems, and understanding the systemic causes of complex failures.
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