Is Human Error a Design Problem or an Excuse?

How to avoid melting down a nuclear reactor.

The Netflix documentary Meltdown: Three Mile Island looks at the 1979 disaster at Three Mile Island (TMI), Pennsylvania and what led to the United States being thirty minutes away from complete nuclear meltdown. It is also a classic story of design flaws and the importance of what we now know as user experience design.

Background

What happened to almost cause a massive nuclear meltdown in the United States? After the incident, investigators discovered that the 150-tons of uranium within the reactor core had rose to a temperature of 4300°F. At 5000°F, the uranium would have melted through the eight-inch steel reactor containment shell, boring through the earth until hitting bedrock beneath the Susquehanna River, and blowing radioactive steam geysers into the air just 90 miles away from Philadelphia.

At the time, human error was to blame but if we look at human error from a UX perspective, should as many incidents be put down to this? In the case of TMI it was a massive failure of design that led to confusion amongst the operators, who never stood a chance of a safe and quick response.?

What actually went so wrong?!

The issues started when a blockage in the cooling system triggered a series of warning lights and alarms. In a panic, confused operators rushed to turn them off. The control panel gave no clear explanation of how the plant actually worked, grouping information in meaningless ways. For example, the panel indicating reactor leaks was next to the one for lift problems; investigators later found that a single red light could mean 14 different things, some bad, and some good. None of the operators could discern the cause and effect of all the problems they attempted to address what started as a minor blockage.

But remember, this is just where things started. It gets worse!

The real issue came from a release valve at the top of the cooling reactor. This valve was so crucial to the operation of the tower that it had its own light in the control room….. Here’s where things got dangerous. The light was only wired to the switch, not the valve. Meaning it could only communicate whether someone had turned the switch on —and not whether, in fact, the valve had actually been closed. Because the light only gave an intention of closing the valve and not actually closing it, the valve stayed open for hours as water boiled away from the reactor core, sending the temperature inside rising to the eye watering 4300°F.

What lessons should I learn from a nuclear meltdown?

The problem with the valve light was the feedback information it was (or wasn’t) giving the operators. If we look at an app or website or piece of technology, and the feedback isn’t right, we’ll never really learn how it works. Take this feedback off a website or away from a nuclear reactor control panel, it’s the correct feedback mechanisms that teach us how the world works. The mechanisms show us what is important and give us priorities in what could be a world full of meaningless lights and alarms. This is where design principles are key in any development process, whether it’s product, service, business strategy, public or private sector. In times of pressure, we resort to intuitions. It’s in these times we need to ensure processes are clear for everyone. User Experience is a way to deliver new products and processes that seamlessly respond to our intuitions of how things work.

Does your company have a CDO, design strategist, even a designer that is working on problem solving? It might be time.