(101b) The Day a Three Mile Island Event Did Not Happen

In 1986, while I was a new engineer at a nuclear power plant, the plant experienced a total loss of feedwater event when multiple systems and equipment failed, including safety critical equipment. This event could have led to a meltdown of the reactor core, similar to the Three Mile Island Nuclear Plant event several years earlier, but several operators literally saved the day through their actions. Subsequent reviews of the management system failures that led to the equipment failures provided for a wake-up call in the industry to refocus on process safety. The corollaries to process safety events and process safety management systems in the refining and chemical industry were uncanny. How could simple management system / procedural failures have led to a near catastrophe? How did these failures affect an industy, my colleagues, and I? What more can we learn from this event and others?