November 23, 2009 | Mark Paradies

Monday Accident & Lessons Learned: Oopps at Nuclear Plant – Even in High Performance Organizations, Mistakes Can Happen

Nuclear plants are suppose to be high performance organizations where everything is checked and double-checked. They use INPO’s “error prevention tools.” They are used as a model for other industries to aspire to be like.

Now look at the picture below…


That’s not what a fuel bundle is suppose to look like.

That’s an expensive mistake.

Of course, no radiation was release to the general public (after all, this was just a fuel loading accident that cost money but did no environmental or human damage). So the multiple safeguards that are used in the nuclear industry were not completely violated.

But equipment damage was done and the refueling outage was delayed (expensive).

Lesson learned?

No place is immune to human errors.

They can happen in high performance organizations.

That’s why even high performance organizations need advanced root cause analysis to learn reactively … and … hopefully, proactively, to stop problems in the future.

If you would like to learn how to use root cause analysis reactively and proactively to improve performance, please attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Courses held around the world.

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