It’s a while ago since I read Perrow’s “Normal Accidents” and Scott Sagan’s “The Limits Of Safety”, both discussing (among others) the safety of nuclear weapons. This book is the perfect companion to these two books and gives perfect arguments in favour of Perrow’s theory.
The book takes the Titan II accident near Damascus, Arkansas in September 1980 as the central storyline around which he tells the story of nuclear arms development of the USA from the Manhattan Project until today, and especially the safety side. There is much focus on the accidental causing a nuclear explosion in the USA, of course, which would have a wide range of possible adverse effects, like destroying a military base or populated area and of course not in the least accidentally causing a nuclear war. There is also much attention for ‘smaller’ incidents that also can have major effect, including the dispersion of radioactive dust.
The amazing thing is maybe that serious accidents happened, like fires, plane crashes, accidental dropping of bombs or the explosion of the Titan II rocket, but that none of these incidents led to something really MAJOR. No nuclear weapon exploded by accident. General Butler is quoted saying “…we escaped the Cold War without a nuclear holocaust by some combination of skill, luck and divine intervention, and I suspect the latter in greatest proportion”.
The book is extremely well written and while it reads like an action thriller novel it discusses many important safety lessons and safety relevant themes, including:
- Conflicting goals - the dilemma of having weapons that never shall go off accidentally, but always have to work when they must and the clear priority that the armed forces placed on the latter.
- Lack of sense of urgency/acknowledging the problem, or unwillingness to pay for it. This is a very typical phenomenon (also in many other sectors) that one rather wants to invest money in new stuff than upgrade or maintain the existing material.
- Chronic (under)reporting or keeping reports within parts of the organisation (often incidents would not be reported to the specialists).
- The growing of a bad error culture because the people in charge had “created an institutional culture at the Strategic Air Command that showed absolutely no tolerance for mistakes. People were held accountable not only for their behaviour but for their bad luck. “To err is human”, everyone at the command had been told, “to forgive is not SAC policy”.” (page 346)
- That reality trumps fantasy anytime when it comes to accident scenarios. Accidents can be caused in many unforeseen ways and mundane everyday mishaps can through complex interactions lead to major consequences. The book discusses a number of accidents that no one would have thought of in advance; like a nuclear bomb being accidentally released because someone accidentally grabs the manual release in the bomb bay during flight. The accident that I found the most incredible was the Thule Air Base crash where seating cushions took fire and the B52 carrying four nuclear bombs crashed close to the airbase and almost took it out by a nuclear explosion - while it was monitoring the base in case it would be taken out by a Russian nuclear first strike!
- The importance of Management of Change: changed use over time, other than intended can have major unanticipated consequences. For example that B52 bombers would be used for airborne alerts (staying in the air for about a day) or be used almost 80 years after their construction.
- What is acceptable risk and the miss-use (abuse) of probabilities (especially assumed probabilities) to downplay risks.
At the end of the of the book in the Epilogue, Schlosser turns to Perrow and Sagan and echoes Perrow’s sentiment while acknowledging that nuclear weapons couldn’t be un-invented and would need attention in the future. At the end of the book there is also a quick look at other nations with nuclear weapons, especially those who are in the stage of developing them and basically form the greatest risk for accidental explosions or warfare with nuclear weapons.
A book you will find hard to put down.
I’ve read the Penguin pocket version, 2013, ISBN 978-0-141-03791-2