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ready for takeoff
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thank you so much for being here my name is Nicholas means I am
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the lead of the engineering team at Sim where we're building tools to create engine for engineering teams to create and orchestrate slack-based access and
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authorization workflows so if you've got production system access challenges come find me we should talk
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I also co-host a podcast called managing up if you're into managing stuff management stuff you might be interested in it check it out at managing up dot
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show today though I'm here to tell you a story dotted along the coast of Japan usually
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a significant distance from the water are Stones like this one left there by Anonymous members of
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previous generations and they all say something very similar a home built high is children's relief
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remember the disastrous giant tsunami do not build homes below here
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now Japan is one of the most seismically active countries on Earth built on the Pacific Ring of Fire these Stones make
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it obvious that they are also no stranger to tsunamis massive ocean waves driven by earthquakes under the sea
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so given the risk of tsunamis you might be surprised by this map of nuclear power plants in Japan
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every single one of them is right on the coast why is that well when you picture a nuclear power
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plant what Pops to mind it's probably something like this
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and credit to The Simpsons this actually is a fairly accurate rendering of a two unit pressurized water nuclear power
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plant but the thing in this picture that you probably most closely identify with nuclear power is the two hyperboloid
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cooling towers Standing Tall over the rest of the plant now the funny thing about this is that there's nothing inherently nuclear about
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them every thermal power plant nuclear fossil fuel needs a source of cooling there are plenty of non-nuclear power
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plants that use hyperbola towers and plenty of nuclear plants that use other kinds of cooling like these mechanical draft arrays
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the post-war economic boom in Japan meant that by the 1970s Japan was starving for electricity
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we need to build a bunch of nuclear power plants in a hurry and on a budget one of the best ways to reduce time and
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cost is to build them on large bodies of water to use the ocean as a giant heat sink so you don't need cooling towers at
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all and that's what Japan did over and over again one of those plants on the sea with no
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cooling towers is Fukushima daichi a six unit boiling water nuclear power plant with a generating capacity of 5.3
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gigawatts owned and operated by the Tokyo Electric Power Company or tepco it's located right on the Pacific coast
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in Northeast Japan the reactors at Fukushima daichi went online between 1971 and 1979 all of them
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boiling water reactors designed by General Electric in the United States unit 1 is a slightly smaller older
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design than the rest of the fleet unit 6 is a slightly larger newer design March 11 2011 started like any other day
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at the plant units one two and three were all running as they say in the nuclear industry hot straight and normal running at full power generating
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electricity unit 4 was offline being refueled units five and six had both just finished being refueled and were
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undergoing testing in preparation for for restarting but off the coast of Japan and the
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Earth's crust trouble had been brewing for more than a thousand years as the Pacific Plate continually
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subducts under the akhotsky plate that tohoku and the rest of Northeastern Japan sit on potential energy is built up like a
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spring being compressed on March 11 2011 at about 2 46 in the afternoon that potential energy finally
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overcame the friction between the plates holding it back and became kinetic energy in the form of a magnitude 9.1
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earthquake the Epson was about 45 miles off the coast but subduction zone Mega thrust
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Quakes like this one typically involve a rupture along hundreds of miles of fault line in this case the fault line that
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ruptured roughly parallels the northern coast of Japan the force of this rupture was such that
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Northern Japan moved about eight feet closer to North America and the tilt of the Earth's axis shifted
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somewhere between 6 and 10 inches we're not really sure it was the most powerful Quake to ever
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strike earthquake prone Japan when the shaking started masal Yoshida
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director of Fukushima daiichi was in his office processing some of the paperwork that was ubiquitous in the tepco bureaucracy
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Yoshida kept expecting the shaking to taper off but it just got stronger
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for six long minutes the ground shook
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when it finally stopped he knew there would be much to be done so he threw on his hard hat ran out of his office he fought his way through this mess right
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outside his door and headed towards the plant's earthquake proof Emergency Response Center
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the control room for units one and two was in disarray right after the quake as the shaking stopped The Operators immediately ran to the panels and
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started figuring out the state of the plant calling out various measurements to akua azawa the shift supervisor in
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charge of units one and two that day they were able to quickly see that the plant's automated emergency systems had
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done exactly what they were supposed to do now to understand what happens next you need to know a little bit about how
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nuclear reactors work so let's do a crash course the heart of any thermal power plant is
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the heat source in a nuclear reactor it's the uranium fuel rods that create the heat generating nuclear chain
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reaction the fuel rods are contained in a pressure vessel and surrounded by water that in a Boiling Water Reactor boils to
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steam at the top of that pressure vessel and there are also Neutron absorbing control rods that can be inserted in the
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core to slow or stop the chain reaction as water boils to steam at the top of the reactor vessel it expands and the
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energy from that expansion turns a Turman connected to a generator this is how the plant actually generates electricity
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as after the steam turns the turbine it's directed into a condenser where it turns back into liquid water and then a
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circulation pump pumps that liquid water back into the Reactor Core this is crucial because water constantly boiling
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to steam at the top of the reactor pressure vessel has to be continually replaced to keep the fuel rods from
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overheating and Fukushima daichi like most nuclear plants there are sensors to detect Earth movement when there's an earthquake the
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reactor control system automatically scrams the reactor putting the control rods all the way into the core and instantly halting the nuclear chain
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reaction this happened exactly as it was supposed to in all three active reactors
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but the fuel in the core of a nuclear reactor gets so hot that cooling circulation must be maintained for days
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after shutdown to continue carrying this Decay heat away from the fuel so the fuel rods don't melt
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only once that cooldown has happened has the plant reached a safe state of cold shutdown
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that means the reactor's circulation pumps must be kept running even though the core is shut down and that's a problem when a giant earthquake has
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severaged your plant's connection to the electrical grid thankfully the plant had redundant answers to this situation first each
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reactor has two enormous diesel backup generators just one of which provides adequate energy to maintain circulation
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through the core these generators had all started automatically as soon as the plant lost its grid Connection in case in case the
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generators failed each control room also had a bank of lead acid batteries to power instrumentation and control valves
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for several hours second each reactor had a passive cooling mechanism that would function without any external power at all in
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unit 1 that took the form of an isolation condenser it was a large tank of water open to the atmosphere Steam
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from the reactor pressure vessel could be directed through a heat exchanger in the isolation condenser where it would
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turn back into water and Flow by gravity back into the pressure vessel with the water in the isolation condenser boiling off to steam in the atmosphere to
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release the Heat the isolation condenser could passively cool unit one for three days before
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requiring more water to be added without any human intervention at all the slightly newer units two and three
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because they're larger have a different passive cooling system the Reactor Core isolation cooling system or rixi for
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short the rixxy is a more complicated system but the basics are that the steam from the reactor pressure vessel drives a
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pump that replenishes the water in the Reactor Core it can be topped up from an external tank if the water level drops
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when the backup generators kicked on at Fukushima daichi these passive cooling systems all kicked into gear as well
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at this point despite being without power from the electric grid the plant was well on its way to a controlled
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shutdown everything was well in hand when the first tsunami warning went out
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a few minutes after the Quake the initial prediction for the Fukushima area was just around 50 centimeters 18 inches
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that would later be revised several times but never beyond the plant's 19-foot tall sea wall
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they made a precautionary announcement over the plant's PA system that there was a tsunami warning and that workers should move to Higher Ground just in
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case but that was the extent of their preparations in reality
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the largest of the three tsunamis heading towards the plant was more than 40 feet high and it was
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moving at 100 miles an hour when it arrived the operators in the
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windowless control room had no idea they were shocked when one of the operators announced a new critical alarm at 3 37
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PM the diesel generators have tripped a few seconds later the overhead lights in the control room
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went out then slowly randomly panel by panel their instruments all went dark
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the constant warbling of alarms from the unhappy plant was replaced by an eerie silence a few seconds later izawa broke the
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Silence by shouting station blackout they had no electricity at all
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a situation never considered realistically possible in all of their emergency preparations
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the reactors at Fukushima daiichi are located on the 10 meter level 10 meters above sea level the huge diesel backup generators along
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with the power switching equipment and lead acid backup batteries were all in the basement of the auxiliary building
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on the four meter level when the tsunami arrived and inundated their sea wall
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they were all destroyed The Operators found themselves trying to operate three nuclear reactors that just
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minutes before had been generating over two gigawatts of power with no instrumentation
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and no remote valve controls their immediate concern was unit one
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the operating manual for unit 1 said that to protect the reactor's pressure vessel the reactor's cooldown rate couldn't exceed 55 degrees Celsius per
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hour about 20 minutes after the Quake The Operators realized that it was cooling too fast and so they'd begun cycling the
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isolation condenser in and out of service they had just cycled the condenser back off at 3 34 pm
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three minutes before they lost power the rixi systems in unit two and three would keep them under control for the
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time being but unit one because of unlucky timing was completely without Cooling
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without coolant circulating carry heat away all of the water in the core will boil the Steam and this causes a couple
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of things first without cooling the nuclear fuel rods will eventually get hot enough to melt
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second because water expands when it turns to steam the pressure in the pressure vessel Rises
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if pressure gets high enough it will eventually turn into a giant steam bomb and explode
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spraying radiation into the environment now given fukushima's location that could make Tokyo uninhabitable for
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decades that fact was in the back of everybody's mind there are a few things they needed to do
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to get unit 1 back under control and they started working on them all at the same time first they knew the instruments in the control room would
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work under DC power so while one team began looking at wiring diagrams to figure out how to how to hook up electricity to all their instrumentation
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another team went out and began harvesting car batteries from the cars parked around the site
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well they worked on that another team began working on figuring out how to get unit get water into the core of unit one
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of the first things that plant director Yoshida had done when the tsunami hit was to request fire engines from two nearby Japan self-defense floor spaces
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now this wasn't in the plant's emergency operations manual but Yoshida predicted correctly that they would need some way
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to pump water and fire engines were the first thing that came to mind meanwhile katsuaki hirano had just
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arrived at the unit one control room he was a shift supervisor from a different team he wasn't scheduled to work that day at all but he had made his way to
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the plant to help as quickly as he could after the earthquake he had the idea of using unit one's firefighting pipe Network to Route water
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to the Core he led multiple Expeditions into the dark reactor building to manually turn the five valves necessary to Route water
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from the fire pipes into the core ano and a partner returned from their final Expedition
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around 9pm by 11 pm radiation levels at the reactor building airlock were so high that
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further entry was prohibited by Yoshida so it was fortunate that hirano's expedition was one of the first things
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that the operating crew did the plant had three fire engines on site one of them had been destroyed by the
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tsunami a second couldn't get to unit one because of tsunami damage to roads the third however was just behind an
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electronic security gate at unit three but electronic Gates don't work with the power out
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by around two in the morning they finally broken the lock on the security gate moved the fire truck into place and
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had begun injecting water into the core of unit 1. unfortunately the water injection they
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were able to accomplish was very slow because of pressure in the reactor vessel once they worked out how to hook
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a hook up the scavenged car batteries to the instrumentation and control room they found that pressure in the pressure vessel was significantly elevated around
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two atmospheres of pressure the only way pressure this high would have been possible was if the fuel had
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begun melting down so relieving the pressure and getting more water in was absolutely critical
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thankfully Yoshida had anticipated this as well and was already working on the necessary permissions to conduct event
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now this is exactly what it sounds like venting likely radioactive Steam from the pressure vessel of the reactor into
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the open atmosphere it was it was a worst case measure to try to save the plant
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any atmospheric release of radiation required government permission and that permission needed to come from this man
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naoto Khan the prime minister of Japan as soon as an emergency had been declared at the plant tepco sent a
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liaison to Khan's office so he had already been briefed on the rising pressure at unit one he readily gave permission for the vent
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as soon as the five kilometer evacuation Zone around the plant was evacuated a process that was already underway
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at the plant izaw and his team had been working feverishly and rapidly deteriorating conditions to figure out how to vent the reactor radiation levels
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were now high enough in the control room being there required wearing full face masks with charcoal filters if radiation was this bad in the control
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room it would be terrible and dangerous in the reactor building they needed to
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figure out a way to vent the plant that would have staff in and out as quickly as possible
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back in tokyocon had finished his middle of the night emergency press conference to announce the vent and he was livid
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it was four in the morning he'd given us permission to vent hours ago why the hell hadn't they vented unit
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one yet did they not know what was at stake the tepco yet liaison in his office had
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explained the challenges the staff of the plant were facing but Khan decided he needed to find out for himself what was going on
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so by 5 30 in the morning the day after the earthquake the Prime Minister and his Entourage ran a helicopter on their
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way to Fukushima daiichi at the Fukushima Emergency Response Center there was panic and frustration
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over Khan's visit Yoshida and his staff were now working feverishly to vent unit one and now they had this to deal with
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on top of that they had another problem to solve they were running short of protective equipment and now that the pre the PM and his
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Entourage were coming they had to outfit them as well with their dwindling stocks every time someone entered the radiation
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shielded ERC the face mask that they were wearing had to be discarded because as soon as the seal with their face was
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broken it was contaminated it was decided that Khan would land at a nearby sports field and that he and his
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Entourage would be brought as close to the door of the ERC as possible in a mini bus so that they wouldn't need to
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waste Emergency Equipment on them it was a clever solution tepco VP takaimuto was among the party
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to greet Khan's helicopter when it landed in Fukushima Muto remembers offering kana's standard Japanese greetings very formal along the lines of
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it's very kind of you to come sir now I'm sure he didn't feel this way but that's what Japanese etiquette dictated
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that you said to the prime minister in a situation like this Khan quickly responded why the hell
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haven't you vented yet he proceeded to yell at Muto for the entire bus ride to the Emergency
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Response Center remembers Khan saying repeatedly that he just wanted to know what the problem was
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but then not listening at all he seemed to only want to complain that staff weren't doing their jobs
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when Yoshida and Khan met in the ERC Khan's first words to him what the hell is going on
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rather than Fight Fire with Fire Yoshida calmly explained the situation in detail and as he talked Khan seemed to settle
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finally Khan asked well when are you going to get the vent done more than anything else you must get the vent done
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Yoshida responded calmly again we are of course doing everything we can we have a Suicide Squad preparing to
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enter the radiation field now hearing that there were people willing to risk their lives to conduct the
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dangerous event operation seemed to end the discussion the actual meeting had lasted 20 minutes
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asawa's crew had identified a pathway to venting that would require only require opening two valves the valves were in
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two different areas of the reactor building so they would send two teams of two into the radiation field under
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Japanese law workers are allowed a maximum of 100 millisieverts of radiation exposure during an emergency so everyone put on a personal dissimeter
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alarm like this one and set it to go off at 80 millisieverts agreeing to turn back immediately if it went off
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the first crew made their way to their valve on the second floor of the reactor building it was huge awkwardly placed at the end of a catwalk hard to turn
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but they got it done and we're back to the control room in 11 minutes without coming close to the the 80 millisievert
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alarm the second Cruise valve was in a much more precarious position
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to help us understand here's a photo of an under construction Mark 1 containment structure the thing represented in this
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diagram from earlier their valve was in the basement of the reactor building
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if there had been core damage it was likely that melted fuel would be sitting at the bottom of the pressure vessel
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creating an intense radiation field at the bottom of primary containment as they made their way into the basement the handheld radiation meter They
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Carried was bouncing between 900 and 1000 millisieverts per hour roughly enough to give them their Max dose in
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about 10 minutes when they saw the meter stick at a thousand millisieverts per hour the max that it could read
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they had to turn back there was no way to know how strong the radiation Fields they were walking into were with their
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meter maxed out when they got back to the control room they found that they had received a doses of 89 and 95 millisieverts
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respectively they were the first two workers to dose out and have to be evacuated from the site
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nearly 10 in the morning and the event still hadn't been carried out the operators had gone from elated at the
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success of the first crew to despondent at the situation the second crew encountered they didn't give up
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there had to be a way to vent it one group worked to see if a portable air compressor could remotely operate the
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pneumatic valve while another tried to find a different route to the valve at two in the afternoon the reactor
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pressure vessel was up to eight atmospheres of pressure about two times its rated strength
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things were getting desperate the second crew was just getting ready to make a run for the valve determined to open it no matter what the cost when
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they got a call from the ERC white smoke was coming out the top of the unit one and two shared event stack
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slowly pressures in the reactor pressure vessels started to drop they must be venting
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there was no way they could know for sure without instrumentation but the attempt to open the valve pneumatically must have worked they felt a tremendous
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sense of relief that relief would last for about an hour
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this is what an off-site monitoring camera saw at 3 36 pm on Saturday March the 12th
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workers scrambled upon protective gear to figure out what had happened their initial fear was that venting the reactor was too little too late and the
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reactor pressure vessel that just exploded but thankfully that wasn't what had happened
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this is what a fuel bundle looks like for a Boiling Water Reactor a given reactor would have several of these
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bundles arranged in its core for optimal reactivity most of the tubes you see here are the actual fuel rods made of zirconium alloy
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and filled with uranium fuel pellets now zirconium is the metal of choice for this because it's very corrosion and
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heat resistant while also being essentially transparent to the neutrons that sustain the nuclear chain reaction as the core gets hot enough to melt it
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though it's corrosion resistance runs out and it starts rapidly oxidizing
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and a reactor pressure vessel filled with steam the sudden oxidization reaction rips the surrounding water molecules apart forming zirconium oxide
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and hydrogen gas which is very flammable as the smoke and debris settled this is
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what they saw given the shaking of the earthquake and the significant over pressurization of the reactor's primary containment it's likely there were
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plenty of places the hydrogen created by the Meltdown could have slipped through it accumulated at the top of unit 1's containment building and all it took was
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one Spark the explosion blew radioactive debris across the site it also caved in a door
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and an air conditioning intake at the Emergency Response Center contaminating the one relatively radiation free space
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remaining on the site the work of keeping units two and three from melting down got that much harder
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and circular the situation at unit three was getting pretty critical the rixie had been passively cooling the reactor
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since the power loss but heat was starting to build and they were running out of fresh water on site Yoshida made the call to use fire trucks
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to begin injecting sea water they've been trying to avoid this because they were still hoping to restart their reactors someday and the
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salt in the sea water would ruin the reactor meaning it could never generate power again but they had to keep it from exploding
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that was the priority back in Tokyo prime minister Khan heard that they were considering sea water injection and demanded that they not do
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it one of his small group of technical advisors had mentioned a non-zero chance that the salt in the seawater might
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cause the reactor to start reacting again to become critical in reality the chance was minuscule and an
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exponentially smaller risk than a reactor explosion Masala Yoshida had no intent of
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complying before a video conference with tepco execs in Tokyo he told his staff if they
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order me to Halt seawater injection I will relay the order to you so that they can hear me you are not to respond and you were not
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to stop seawater injection it's our only chance unbeknownst to them core damage at unit
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3 had already occurred and if they had stopped the seawater injection it might well have exploded
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the next day unit 3 would experience a hydrogen explosion just like unit one unit four which wasn't even running at
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the time of the earthquake would go on to explode as well from hydrogen gas suspected to have leaked in from unit 3 via their shared vent stack
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they later later learned that unit 2 had experienced core damage as well and it likely avoided a hydrogen explosion only
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because its reactor building was damaged enough from the other two explosions to vent the hydrogen instead of letting it accumulate
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you can see units one through four in this photo three of the four exploded three of the four in a state of partial
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meltdown at this point radiation levels at the site were making it hazardous to walk from building to building with staff
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running everywhere they needed to go wearing heavy protective gear so late in the evening of the 14th
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Yoshida made the difficult decision to evacuate most of the staff to Fukushima daini daiichi's sibling plan a few miles
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away and only keep a volunteer Skeleton Crew on site Yoshida didn't allow anyone under 45
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years old to stay because people under 45 might still have children and radiation poses more danger to them
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those over 45 were free to leave as well if they wanted nobody was forced to stay everyone who chose to stay knew that
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there was a significant chance they'd suffer dangerous radiation exposure possibly even die
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but they felt the responsibility of the rest of Japan to ensure that the plant didn't cause wider contamination
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in the end there were 68 plus Yoshida left at the plant
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this group would be referred to by the media as the Fukushima 50. back in Tokyo prime minister Khan heard
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that conditions of the plant were deteriorating and shockingly the tepco planned to abandon the plant they can't do that it would surely
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explode furious at the news Khan calls a middle of the night meeting the tepco liaison a Khan's office
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quickly clarifies the misunderstanding that there's no intention of abandoning the plant just evacuate non-essential personnel
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but it doesn't matter Khan is finished at this point he uses his authority to create a joint
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response office with himself as the lead taking over control of the response at Fukushima from tepco
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despite knowing that there was never any intention to abandon the plant Khan carries on like there was in the internal video conference announcing the
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change if things go on like this Japan is done for abandoning the plant is Unthinkable
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you must risk your lives on it if necessary if you abandon the plant tepco will be destroyed you can run but you'll
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never get away these were his words to a room full of people who had just decided to sacrifice
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their lives if necessary to save this plant at this point masal Yoshida had had
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enough at the front of the room video conference cameras still running
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Yoshida stands up turns his back on the prime minister and lowers his pants
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he makes it look like he's just tucking his shirt back in but everyone in the room knows what he's really doing in Japan's formal business culture
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turning your back on a superior is a huge etiquette faux pas but Yoshida took it exponentially
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further than that now as the plant slowly came further and
00:25:20.940
further under control and danger became less evacuated workers came trickling back in to help it would take the better part of the year but finally on December
00:25:27.480
16th tepco declared cold shutdown at Fukushima all reactors were below 100 degrees Celsius and all radiation leaks
00:25:33.779
had been substantially contained this photo from earlier this year shows the condition of the plant today
00:25:39.000
a tank farm sprang up around the plant to contain all the contaminated water unit 1 and 2's buildings were able to be
00:25:44.100
repaired but new containment structures had to be built around units three and four decommissioning work has begun and will
00:25:49.740
likely take the next 30 to 40 years to complete in the history of new commercial nuclear
00:25:55.200
power generation there have only been five reactor meltdowns three of these were at Fukushima to fully understand
00:26:01.080
the severity of the accident let's put it into context by comparing the amount of radiation it released into the environment
00:26:06.480
the first commercial reactor to partially melt down was at Three Mile Island in Susquehanna Pennsylvania
00:26:11.720
Islands contained Hydro hydrogen explosion and subsequent venting released approximately 626 gigabyte
00:26:18.059
rolls of radiation into the atmosphere Fukushima daichi with its three partial
00:26:24.179
meltdowns and three uncontained hydrogen explosions is estimated to have released 780 petabek rolls of harmful radiation
00:26:30.900
Three Mile Island is represented as a one pixel dot here I promise it's there but the correct side on this slide would
00:26:37.080
actually be a circle 6 10 millionths of a pixel across that's how much larger Fukushima was to through Mile Island
00:26:45.059
but compared to the largest nuclear accident of all time Fukushima looks pretty small
00:26:51.720
Chernobyl a Soviet rbmk reactor designed famously with no containment of any kind
00:26:57.179
had exploded and there was nothing to keep it from going straight up into the atmosphere to the tune of 5.2 exobecerals around seven times as much
00:27:04.919
radiation as Fukushima it was a huge accident but let's say that the operators at Fukushima had
00:27:11.279
failed to establish Cooling and relieve the growing pressure in their containment vessels and all three running units at Fukushima
00:27:17.279
experience steam explosions an uncontained failure at all three Fukushima daiichi units would have
00:27:23.100
released at least 7.5 exabec rules but because fukushima's reactors had
00:27:28.740
pressure vessels it's likely that would have Amplified the explosions compared to what happened at Chernobyl
00:27:35.340
it's almost impossible to guess how bad the accident at Fukushima could have been
00:27:40.559
if not for the heroic actions of Masala Yoshida Iko izawa and all of the other Brave operators who risk their personal
00:27:46.860
safety at Fukushima to mitigate the accident the only way to have prevented this disaster
00:27:52.679
would have been to move the backup generators to Higher Ground something that tepco was studying but hadn't yet
00:27:57.960
committed to do at the time of the accident it's almost impossible to improve upon the actions The Operators took in the
00:28:04.620
minutes hours and days after the accident so there's nothing The Operators could
00:28:09.779
have done differently to get a better outcome what should we learn from the accident at Fukushima let's talk about nautokan
00:28:17.220
Khan resigned on September 2nd 2011. in no small part because of the situation at Fukushima daiichi not just that it
00:28:24.240
happened but his handling of it his distracting visit the morning after the earthquake
00:28:29.760
his attempted delay of seawater injection his demoralizing pep talk insulting the very people Japan was
00:28:35.820
depending on to keep the crisis from escalating in each case there was one man that countered Khan
00:28:41.880
Masala Yoshida both shielded operators from Khan's interference and rallied them past it when it was unavoidable he
00:28:48.600
deftly handled Khan's site visit he ignored Khan's order to pause seawater injection he very tangibly showed the
00:28:53.820
Fukushima 50 that he would not stand for Khan's disrespect
00:28:58.860
and he did all of this in a culture her seniority and hierarchy are sacrosanct
00:29:05.520
how a really interesting paper published by Dr Ruth Ann heising has some insight for us Dr heising interviewed several
00:29:12.659
employees who were participating in business process redesign teams at large companies these teams were working to make fundamental changes about how their
00:29:18.659
organizations worked part of the process each of these teams went through was process mapping
00:29:23.760
documenting the steps conversations tools and other activities required to complete a Core Business activity like
00:29:29.039
processing an insurance claim or launching a new product these Maps were always surprising for
00:29:34.080
the teams that created them and they often raised existential questions about employees roles in the organization
00:29:39.419
the reason was that they revealed the actual structure of the organization the relationships the information Pathways
00:29:45.899
that were responsible for the organization actually being able to get work done they learned the actual structure of the organization was an organic emergent
00:29:52.679
phenomenon constantly shifting and changing based on the work to be done and often bearing little resemblance to
00:29:58.620
the formal hierarchy of the organization observing the organization is
00:30:03.720
continuously in the making gave employees an overwhelming sense of possibility sparking ambition their
00:30:09.539
experience with the mapping exercise shook them out of their well that's just the way things are learned helplessness towards the bureaucracy and the way that
00:30:15.659
their companies worked we've all trained ourselves over the course of our careers to think that the
00:30:21.480
folks at the top of the org chart know more than we do and they often do have helpful holistic
00:30:27.960
perspective about the company and the industry it operates in but all of the actual work of an
00:30:34.320
organization all of its output happens at the bottom of the org chart and the teams at the edge of the organization
00:30:40.500
leaders at the top may have a wide perspective but the edges are where an organization's detailed knowledge lives
00:30:45.779
and because of that the edges are where the majority of an organization's decisions ought to be made this is where
00:30:51.000
the organic emergent structure that lets an organization actually get work done takes shape
00:30:56.760
which brings us back to yoshida-san ryushu kadoda the author of one of the books I read researching this
00:31:01.980
presentation asks several Fukushima workers how the accident would have been different without Yoshida and most of them answered with some variant of we'd
00:31:07.740
have been lost without him several said something like with Yoshida in the lead we were prepared to die together if we had to
00:31:13.679
when asked why it came down to trust Yoshida made it clear over his years of leading Fukushima daichi that he trusted
00:31:20.100
his operators and their decisions they were able to make decisions and work in such Harmony during the accident but
00:31:25.679
because of the trust he placed in them and Yoshida continually re-earned and
00:31:31.620
reinforced their trust by doing things like standing up to the prime minister
00:31:37.200
so what's the takeaway well depends on who you work for
00:31:43.020
if your management resembles naotocon you're going to have to lean into what the participants in Dr heising's
00:31:48.600
business process mapping exercise learned I'm now focused on inventing the board and not just playing the game
00:31:55.500
trying to see what's really out there and not arguing too much for the limitations that maybe aren't so real
00:32:01.919
you can see this in the way that Yoshida responds to Khan the rules of the game especially in Japan are extreme
00:32:08.159
deference to hierarchy and superiors but the possibility Yoshida was fighting for was not blowing up the plant
00:32:15.659
it's not all Rebellion all the time but it might mean knocking your deference for your leaders down a notch or two and
00:32:22.320
trusting yourself a little bit more so that you can get work done but if your management is more like
00:32:28.080
masal Yoshida your job is to lean into the trust that they give you to try things to use the safety that they
00:32:33.720
create and the guidance they offer to learn and to grow and to push the business forward
00:32:38.760
you likely still have some learned helplessness built up from your career and even with high trust leadership you're still going to have to learn how
00:32:45.779
to create the game rather than play it and if you're a leader I hope the lesson
00:32:50.940
here is obvious I can chart my career by the talks that I've given because they're always around
00:32:56.399
what I'm learning in the moment that I write them my focus right now in leading the engineering team at Sim is to see what
00:33:02.880
happens when a company's whole leadership team leans into the idea that everything important happens at the edge
00:33:08.159
of the company and the rest of us are there to support that to really trust Empower support and
00:33:13.620
guide not dictate and lead by Road our engineering team has grown more and taken on more leadership responsibility
00:33:19.679
than I would have ever thought possible and we're moving remarkably fast because of it because of that autonomy
00:33:26.039
it's been one of the biggest privileges of my career to be there for it I hope everyone in this room gets a
00:33:31.320
chance to experience or maybe even create a team like that at some point in your career good things like this