>> The rules are stupid and inefficient
My go-to example for this is the radiological accident at the irradiation
facility in Nesvizh, Belarus, in 1991. The International Atomic Energy Agency
(IAEA) has a report here: [1]. It's fascinating reading.
To summarise, the facility in Nesvizh was a common type of irradiation faciity
where product, such as food or medical equipment, is sterilised by circulating
it around a radiation source by a system of conveyors.
In Nesvizh, the conveyors would often jam and the operators of the facility
would have to shut down the irradiation process by storing the source in its
safe position inside a dry pit, then enter the irradiation chamber to un-jam
the conveyors [2].
The day of the accident, the operator circumvented all the safety procedures
and entered the irradiation chamber when the source was in the unsafe position
(he thought it was secured). What is really striking is that he would have had
to work really hard to circumvent the physical safety mechanisms in place to
stop this from happening. The irradiation chamber was built as a spiral maze
with thick concrete walls. The entrance to the maze was protected by a
retracting section of floor that exposed a "chasm" considered too deep and
long for a person to jump over it. The way to the center of the chamber, were
the source was, was lined with pressure plates and motion sensors that, if
tripped would trigger an alarm that would cause the source to be automatically
dropped in its safe position. It was basically like a room with traps in a D&D
dungeon.
And yet the operator of the facility managed to circumvent all those safety
mechanisms and accidentally kill himself as a result. He died before he could
explain how he did it- so for example noone has any idea how he managed to
cross the "chasm" in the entrance. But what seems reasonable to assume is that
he had done this many times before.
The reason he did it of course was that sticking to the safety procedures
meant that the operation of the facility would have to be stopped temporarily
- which slowed down production at the facility.
____________________
[1] https://www.iaea.org/publications/4712/the-radiological-acci...
[2] It seems this is a common occurrence in this kind of facility: there are
two other IAEA reports on radiological accidents that started with a conveyor
jam inside an irradiation chamber that caused operators to override safety
procedures. Look for the IAEA reports on the radiological accidents in San
Salvador, El Salvador in 1989 and in Soreq, Israel, in 1990.
My go-to example for this is the radiological accident at the irradiation facility in Nesvizh, Belarus, in 1991. The International Atomic Energy Agency (IAEA) has a report here: [1]. It's fascinating reading.
To summarise, the facility in Nesvizh was a common type of irradiation faciity where product, such as food or medical equipment, is sterilised by circulating it around a radiation source by a system of conveyors.
In Nesvizh, the conveyors would often jam and the operators of the facility would have to shut down the irradiation process by storing the source in its safe position inside a dry pit, then enter the irradiation chamber to un-jam the conveyors [2].
The day of the accident, the operator circumvented all the safety procedures and entered the irradiation chamber when the source was in the unsafe position (he thought it was secured). What is really striking is that he would have had to work really hard to circumvent the physical safety mechanisms in place to stop this from happening. The irradiation chamber was built as a spiral maze with thick concrete walls. The entrance to the maze was protected by a retracting section of floor that exposed a "chasm" considered too deep and long for a person to jump over it. The way to the center of the chamber, were the source was, was lined with pressure plates and motion sensors that, if tripped would trigger an alarm that would cause the source to be automatically dropped in its safe position. It was basically like a room with traps in a D&D dungeon.
And yet the operator of the facility managed to circumvent all those safety mechanisms and accidentally kill himself as a result. He died before he could explain how he did it- so for example noone has any idea how he managed to cross the "chasm" in the entrance. But what seems reasonable to assume is that he had done this many times before.
The reason he did it of course was that sticking to the safety procedures meant that the operation of the facility would have to be stopped temporarily - which slowed down production at the facility.
____________________
[1] https://www.iaea.org/publications/4712/the-radiological-acci...
[2] It seems this is a common occurrence in this kind of facility: there are two other IAEA reports on radiological accidents that started with a conveyor jam inside an irradiation chamber that caused operators to override safety procedures. Look for the IAEA reports on the radiological accidents in San Salvador, El Salvador in 1989 and in Soreq, Israel, in 1990.