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North American Network Operators Group Date Prev | Date Next | Date Index | Thread Index | Author Index | Historical DOE Review of Criticality Accidents
Although published last year, I only learned about this report this year. Las Alamos National Labs published an update to the 1967 publication Review of Criticality Accidents. Ok, I know, what does a study about nuclear reactions has to do with Internet network operations. The answer is found by looking at the underlying causes of the accidents. Unless you are a nuclear engineer, you can skip directly to the chapter "C.OBSERVATIONS AND LESSONS LEARNED FROM PROCESS CRITICALITY ACCIDENTS" It is important to note that there have been no accidents that were caused by a single failure.That is, there were always multiple causes for each of the 22 accidents.It is also noteworthy that equipment failure or malfunction was either a minor or a non-contribut- ing factor in all of the accidents. All accidents have been dominated by design, managerial, and operational failures. The focus for accident prevention should be on these issues. http://lib-www.lanl.gov/la-pubs/00538245.pdf
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