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Started by Pete Lindgren (@petelindgren) ·

Three Mile Island was partly an interface problem

A relief valve stuck open, but the light on the control panel only showed that the valve had been told to close, not whether it actually had. The operators trusted the light while alarms went off by the dozen. Afterwards the industry got a lot more serious about control room design and human factors.

6 sources · 54 min down the hole

How I got here

Started with
Was Three Mile Island caused by bad design?
Ended at
Charles Perrow

The Trail

  1. “three mile island control room indicator light” (google.com)
  2. Three Mile Island accident (en.wikipedia.org)
  3. Pilot-operated relief valve (en.wikipedia.org)
  4. Ergonomics (en.wikipedia.org)
  5. Normal Accidents (en.wikipedia.org)

    Perrow's argument: in tightly coupled complex systems, some accidents are basically inevitable

  6. Charles Perrow (en.wikipedia.org)

Keep going