Monday, November 17, 2014
A few weeks ago, in a fit of despair, I wrote a blog post decrying grammar Nazis everywhere. Maybe typos don’t matter, I said.
Maybe some typos, however, do matter.
Consider this (emphasis mine):
But LANL has never publicly acknowledged the reason why it switched from clay-based litter to the organic variety believed to be the fuel that fed the intense heat. In internal emails, nuclear waste specialists pondered several theories about the reason for the change in kitty litters before settling on an almost comically simplistic conclusion that has never been publicly discussed: A typographical error in a revision to a LANL policy manual for repackaging waste led to a wholesale shift from clay litter to the wheat-based variety.
The revision, approved by LANL, took effect Aug. 1, 2012, mere days after the governor’s celebratory visit to Los Alamos, and explicitly directed waste packagers at the lab to “ENSURE an organic absorbent (kitty litter) is added to the waste” when packaging drums of nitrate salt.
“Does it seem strange that the procedure was revised to specifically require organic kitty litter to process nitrate salt drums?” Freeman, Nuclear Waste Partnership’s chief nuclear engineer at WIPP, asked a colleague in a May 28 email.
Freeman went on to echo some of the possible reasons for the change bandied about in earlier emails, such as the off-putting dust or perfumed scents characteristic of clay litter. But his colleague, Mark Pearcy, a member of the team that reviews waste to ensure it is acceptable to be stored at WIPP, offered a surprising explanation.
“General consensus is that the ‘organic’ designation was a typo that wasn’t caught,” he wrote, implying that the directions should have called for inorganic litter.
Officials at LANL declined to comment about whether a typographical error led to the switch to organic kitty litter.
Then again, which is worse: The error, or those who follow the error unquestioningly?
Because it seems easy to me to pass this off as an error – the fault of some minor functionary who fat-fingered something that subsequently got missed by people who should have known better. And I say this not because I’m a minor functionary functionarying in a capacity similar to the procedure-writer who is probably sweating bullets as this story unfolds.
In nuclear space, we’re trained to have questioning attitudes. If something doesn’t look right – even after the procedure is revised – we’re supposed to question it, even at the risk of stopping work. And it’s clear in reading the rest of the New Mexican article about this incident, the culture of questioning at Los Alamos National Laboratory is what’s broken, typographical error or not. The root cause isn’t the error – it’s what happened with the procedure after it was published.
The typo is part of the classic “Swiss cheese” model of system failure. All systems have weaknesses in them – so the goal is to pass change through multiple systems in the hope that if an error passes through the weakness in one layer, it’s caught by a strength in another layer. Errors are only catastrophic if they pass through the weaknesses of successive layers.
So I approach this area with a lot of humility – not smugness since this is an example of someone else in the cagal. It could happen where I work, and it’s not fun to think about it. Reading about this episode encourages me to sharpen my saw, to make sure I’m not the weakness in my portion of the process here.
And I have an example today where keeping atop the review process of a document helped us avoid an error – it would likely not have caused catastrophe, but certainly could have resulted in a delay and a necessary revision of a procedure. Thankfully, one of my reviewers caught an error that we were able to fix before the procedure went into use. That’s a sign of things working.