Lack of Safety Culture That Contributed to the Chernobyl Disaster

...

Deputy Chairman Shcherbina, was an experienced, very demanding administrator. He applied this same leadership style and methods to the power industry that he applied to the gas industry where he has served as its long time minister. While the concepts of construction may be similar, there are significant technical differences between gas production and nuclear power production. This is evident in the appointment of Deputy Minister A.N. Semenov to direct nuclear power plant construction. While he was educated and experienced at building power plants, they were hydropower not nuclear power. (Medvedev, 1989) At the Chernobyl facility, construction was “completed” and electrical production started on December 20, 1983 however, the reality was it was six months before the first electricity was produced in June 1984. This is because it was a normal practice in the Soviet Union to announce a project completed, then solve any problems with it later. This way project managers can say that the production deadline was met, allowing them avoid any negative backlash from superiors. (World Information Service on Energy, 2011) This lack of safety culture sets the stage for the Chernobyl accident, the largest nuclear accident in the world to date.

The Test

Engineers at the Chernobyl facility needed to conduct a test to determine if the reactor turbines could produce enough electricity to keep the reactor’s cooling system running in case of a power outage until the backup generators could come online. In January of 1986, plant manager, V.P. Bryukhanov, sent the test proposal to the general designer of the reactor at Gidroproyekt for approval to conduct it. The fact that he did not receive an answer did not bother him as it was typical of the political environment in the Soviet Union at the time which was one of secrets and unquestioning loyalty.

After not hearing back from the general nuclear reactor designer at Gidroproyekt, Plant Manager Bryukhanov decided to proceed with the test. The test same was previously attempted before the reactor became operations in March 1984 and failed. The test was needed to see if there was enough inertia in the water cooling system to continue to cool the reactor in the event of a sudden loss of electricity which powered cooling pumps until the backup diesel generator could come fully online. Because he was scheduled for a meeting with the Communist Party in Kiev at the time of the test, he entrusted it to supervising engineer Anatoly Dyatlov to oversee it. The problem was that Dyatlov had never supervised a safety test before; a critical management mistake on the part of Bryunkhanov.

On the day the test, April 25, 1986 there was a delay as power demands required the Chernobyl 4 reactor to remain in full production. It would not be until the early morning hours of April 26th that the test would be conducted but not by the day shift who was familiar with the test, but the night shift who had fewer experienced operators and who were not prepared to conduct the test. In order to allow the test to be conducted, a number of safety systems were removed as well as the removal of more than the prescribed graphite cooling rods. Once the test begins the cooling capacity decreases much more rapidly than anticipated and the core becomes unstable. Extra cooling pumps are turned on but cause a drop in pressure which reduced the cooling capacity rather than increase it.

Under normal conditions the built in safety systems would have activated, control rods would have automatically dropped, emergency cooling pumps would have activated as well as the automatic emergency shut-down system would have kicked in but these have all been disabled for the test. Thirty-six seconds into the test, Leonid Toprunov, responsible for the controls rods presses a special button for an emergency shutdown but it is too late. As the control rods start to descend, they get stuck because they have become deformed due to the huge increase in the steam pressure. At Fifty-six seconds in to the test, pressure in the reactor is so high that it blows the 1000 ton lid that is above the fuel elements off and the first radiation starts to leak. With the lid off, oxygen is allowed into the reactor allowing for a graphite fire to start. Diatlov, doesn’t believe that an explosion has occurred and sends out two operators to investigate; both were killed by radiation. At this point, Alexander Akinhov, the night shift supervisor is still not convinced there has been an accident and orders the operators to continue to add cooling water resulting only in creating a larger steam cloud which to carried large amounts of radiation and debris into the outside. (World Nuclear Association, 2009)

Not Following the Rules

The accident at Chernobyl is indicative of a lack of safety culture. An interview with Operator Uskov of the day shift later said “We often don’t see the need to follow the instructions to the letter, because rules are often infringed all around us.” He went on to say that during training it was constantly repeated that “a nuclear power plant cannot explode”. (World Information Service on Energy, 2011) In another interview, Operator Kazachov said “We have often had fewer control rods than were required, and nothing ever happened. No explosion, everything just went on as normal” (World Information Service on Energy, 2011) this feeling of normalcy is indicative of the Abilene Paradox and of the culture of the Soviet Union at the time. Individuals within the organization also did not want to “not rock the boat” individuals within the organization did not say anything that would put their personal career in jeopardy. They approached their jobs with the attitude “that’s the way we have always done it” which is constant in many major accidents.

The Space Shuttle Challenger for example, exploded 73 seconds after take-off on January 22, 1986. The cause was later determined to be caused by a faulty rubber O-ring seal that sealed joints on the booster rockets which became fragile during colder temperatures. Lack of communication between the manufacturer and NASA about how the O-rings would perform at lower temperatures contributed but because other shuttles had been previously launched in similar conditions successfully, the consensus was to proceed rather than reschedule…..because “that’s the way they had always done it.”

Safety Culture Defined

In the aftermath of the Chernobyl accident the term Safety Culture came into existence. The United States Occupational Safety and Health Administration (OSHA) defined safety culture as the shared beliefs, practices and attitudes that exist in an organization.

...