Nine Megaton Risk, Simple Solution

Damascus, Arkansas, September 18th 1980. An inter-continental ballistic missile site maintained by the US Air Force.  The site is now quite old.  The missile, a Titan II, has a warhead three times more powerful than the combined power of all the bombs dropped in World War II, including the two atomic bombs.  The missile is powered by two fuel tanks, one with highly flammable liquid rocket fuel and a separate tank of highly volatile oxidiser.  The two are meant to mix in the motor and power the warhead to a presumed target in the Soviet Union, thousands of miles away.

The airmen who maintain the rocket are all 18-20 year-olds.  Today, two airmen arrive in their truck to perform maintenance, one a trainee, and they pass through several highly secure gateways to get to the missile launch shaft, equivalent to a 14-storey building going down into the ground.  They are required to look at the oxidiser tank on which the pressure is low, but the hydraulic ramp they need to work on is out of order.  They wait hours for it to be fixed.  When it is fixed, they realise they have left the right tool for the job out in the truck, beyond all the secure gateways.  So, they decide to make do with a different wrench, an old heavy tool with a socket at the end that doesn’t quite work as it is meant to, but the more experienced guy has used this tool before.  They manage to get the cap off the tank.  One passes the socket to the other, but it drops. Tools are often dropped, it seems. Unfortunately, this one falls through a gap between the hydraulic ramp and the rocket; the gap should not be there, but the rubber fitting has worn away.  The heavy steel socket falls 70 feet and hits the launch pad.  It then ricochets off and punches a hole in the fuel tank that then starts to leak.  They raise the alarm but don’t quite own up to the whole story.  Half an hour later it is too late – it was probably always too late, from the moment it happened – and the site is evacuated.

The leaking fuel reaches a critical amount in the air, and it explodes, throwing slabs of concrete the size of buses up into the air.  The nuclear warhead is found a quarter of a mile away in a ditch.  It did not go off.  If it had, it would have wrought destruction over 400 miles in every direction.

The result of the investigation is that maintenance crews will wear lanyards, tying tools to their bodies, so tools aren’t dropped.  If the tales of dropped tools had been listened to, or if a risk assessment had been done, looking at what could really go wrong in that highly complex and dangerous environment, they might have come up with something before the event.  And at the end of the day, what would have prevented what might have been the worst nuclear disaster ever, is a simple lanyard..

 

 

Story source: The American Life – podcast

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