Talking head
RailsConf RailsConf2018

This presentation, by Nickolas Means, is licensed under a Creative Commons Attribution ShareAlike 3.0
80x15

On March 28, 1979 at exactly 4:00am, control rods flew into the reactor core of Three Mile Island Unit #2. A fault in the cooling system had tripped the reactor. At 4:02, the emergency cooling system automatically kicked in as reactor temperature continued to climb. At 4:04, one of the operators switched the emergency cooling system off, dooming the reactor to partial meltdown. Why? Let’s let the incredibly complex failure at Three Mile Island teach us how to dig into our own incidents. We'll learn how the ideas behind just culture can help us learn from our mistakes and build stronger teams.

Rated: Everyone
Viewed 505 times
Tags: There are no tags for this video.