SAFETY, RESPONSIBILITIES AND RIGHTS

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SAFETY, RESPONSIBILITIES AND RIGHTS

Safety and risk - assessment of safety and risk - risk benefit analysis and reducing risk - the three mile island and chernobyl case studies.

Collegiality and loyalty - respect for authority - collective bargaining - confidentiality - conflicts of interest - occupational crime - professional rights - employee rights - Intellectual Property Rights (IPR) - discrimination.

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THE ENGINEER’S RESPONSIBILITY FOR SAFETY

• Consumers can be classified into

active consumers

passive consumers

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The IEEE code of ethics says three points namely

• To accept responsibility in making decision consistent with safety, health and welfare to the public and to disclose promptly factors that might endanger the public or the environment.
• To improve the understanding of technology, its appropriate application and potential sequence.
• To maintain and improve the understanding of technology and its appropriate applications.

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• SAFETY
• Risks in acceptable limit
• Relative term ‘Fairly safe’, ’most safe’
• Perception based on data and experience.

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Safety for Engineers

• Product designed to reduce accidents

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• Ease of operation

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Safety in

• Product -Ease of operation

-Accident free

• Services -Educate and Train Customers

-Post and pre sales services

• Work place -Clean and Tidy

-Avoid malfunction

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Safety and risk

• The concept of Safety
• Risks
• Acceptability of risks
• Lessons for the Engineer

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The concept of Safety

• Safety means the extent of risk can be accepted by the person or a group under a condition.
• The concept of Safety was discussed using the definition given by William W Lowrance. He defines the safety as “A thing is safe if its risks are judged to be acceptable”. But when we apply William definition we found some drawbacks that are defined using some examples.

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The concept of Safety

• Under Estimation of Risks :
• Over Estimation of Risks :
• No Estimation of Risks :  
• By considering all these things in mind the definition is modified and stated as “A thing is safe with respect to a given person or group at a given time if its risks were fully known if those risks would be judged acceptable to a certain extent”. So only we call as fairly safe or relatively safe.

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The concept of Safety

Engineering and safety criteria for safe design

• The minimum requirements is that the design must satisfy all the applicable laws. For this the legal standards should be made to known everyone.
• If an alternate design is available it should be also explored, that is once a product is produced we should not stop our work.
• The engineers should make attempt so that the consumers do not perform misuse of the products. So the design must be done in such a manner that the misuse is avoided.
• Once the product is manufactured the finished devices should be rigorously tested.
• The main thing is that the engineers must take as much time as possible for designing so that he can minimize future risk of injury.

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The concept of Safety

• Designing of safety
• Define the problem ( need and requirements)
• Generate several solutions
• Analyze
• Test
• Select
• Implement

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RISK

• Potential that something unwanted or harmful may occur
• Subjective
• Personal and Public Risk
• Personal Risk

-Voluntary

-Involuntary

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Safe Design

• Comply with applicable Law, Legal Standards
• Product to be of Accepted Engineering Practice
• Potentially Safer
• Foresee Potential Misuse and design to avoid them
• Vigorous Test in Prototype and Finished product.

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Risks

• “A risk is the potential that something unwanted and harmful may occur” or risk is the possibility of suffering harm or loss.

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• Risk can also be defined as the probability of hazardous consequence being realized.
• R = P _* C

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Risks

A risk may be in any of these categories, namely

• Low consequence and Low Probability
• High consequence and Low Probability
• Low consequence and High Probability
• High consequence and High Probability

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Risks

• The concentration is on the third and fourth type. Third indicated learning incidents and the fourth incident comes under major concern and it requires special attention.

• A DISASTER = A SERIOUS CONTINUED EVENT + A STATE OF UNPREPARENESS

• Titanic ship unprepareness of safety procedure and speed was high

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Risks

The main aspect of the engineer is to assess and find any safety related problems. Linda Fisher formed an agency called Environment Protection Agency (EPA). He formed risk identification procedure as follows.

• Work place inspection
• Management / Worker discussion
• Independent audits
• Job Safety analysis
• Hazard and operability studies
• Accident Statistics

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Acceptability of risks

• William D Rowe says “A risk is acceptable when those affected are generally no longer apprehensive (worried) about it”. Doubtfulness depends mainly on how the people take the risk or how people perceive it. Some of the factors, which is based for risk.

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Acceptability of risks

• Voluntarism and Control : though people know that their actions are unsafe or the action they perform has a high amount of risk is called Voluntary Risk. They perform this for some thrill, amusement and fun. But if we ask a person he says he has full control. Riding motorcycles over rough roads or hills area, car races. They fully know about the risks involved but they do these things for pride and amusement. For example the way in which a motor cycle racer or car racer analysis his strategy or plans his life in which he is proceeding.

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Acceptability of risks (Perception of Risk)

Some of the factors, which are considered, are

• Short term Vs Long term Consequences
• Expected probability
• Reversible factors
• Threshold Levels of risks
• Delayed Vs Immediate risks

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Effect of Information on Risk

• Firm Gains preferred over Gains perceived as risky
• Firm Losses avoided over success perceived as probable

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Acceptability of risks

• Effect of Information on Risk Assessment : The way in which the information for taking a decision has a great influence on the risk factor. Many experiments have proved this and an example has taken to explain this. A harmful disease has broken in a city and the government has taken step to avoid it. It is found that 600 people are suffering and the government found that if the medicine is given then it says some options.

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• Plan A – 400 people will be saved – 72%
• Plan B – 1/3 saved and 2/3 will die – 28%
• Plan C – 400 will die – 78%
• Plan D – 2/3 will die – 78%

• A conclusion is made that the opinion received is based on steady and strong gains. In other words firm losses are specified willn’t being considered.

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Acceptability of risks

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Acceptability of risks

• Job-Related Risks : It depends upon the nature of the job. In most of the cases employees in highly risk jobs, don’t have any options but to undertake them merely because of compulsion. In some more cases safety equipments are not provided properly. Because the tolerance level is very high because of poverty level. Example is working in steal plant, chemical plant. So while designing and equipping the work stations the engineers must consider safety and other parameters.

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• Magnitude and Proximity : our reaction to risk may be affected by the magnification or the personal identification or relationship of the victims. Misperceptions of numbers can easily make us overlook losses that are far greater than the numbers reveal by themselves.

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Lessons for the Engineer

Regarding the public conception of safety, engineers has to face two types of problems, namely

• Optimistic attitude
• Pessimistic attitude

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ASSESSMENT OF SAFETY AND RISKS

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ASSESSMENT OF SAFETY AND RISKS

• Knowledge of risk
• Uncertainties in design
• Testing for safety
• When testing is inappropriate

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Uncertainties in design

• Purpose of Designing
• Application of the Product
• Materials and the Skill used for producing the product

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Testing for safety

• Safety and Risk Analysis :
• Testing of a product carried out to destruction

This method has certain drawbacks, namely.

• Tests are often not done by design and it is done roughly done.
• Assume test data are repetitive nature.
• Short testing procedure because of the shortage of time.

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Testing for safety

• There are four main analytical methods, namely.
• Scenario Analysis
• Failure Models and Effect Analysis
• Fault Tree Analysis
• Event Tree Analysis

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Testing for safety

Scenario Analysis : It is a general and common approach. In this analysis, when testing the safety of a product, a person has to start from a given point and then to study all the different consequences developed gradually from it.

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Testing for safety

Failure Models and Effect Analysis : In this method a person has to systematically examine the failure models of each and every part of the product without giving attention on the causes or relationships among the elements of complex systems.

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Testing for safety

Fault Tree Analysis (FTA) : It is a pertinent technique in analyzing the primary causes of occurrences of an undesirable situation. It is a just opposite of the above-mentioned method. In this testing, a person has to propose the system failure and then finds out the events back to analyze the possible causes at component level. These methods are more useful in emergency situations.

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Testing for safety

Event Tree Analysis(ETA) : It has been found to be very useful in identifying a potentially hazardous situation in the plan. This analysis is the reverse of the fault tree analysis. It is mathematically oriented version of scenario analysis.

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Testing for safety

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Testing for safety

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Risk Analysis

• Define Alternatives
• Identify the consequence of the action taken
• Quantify the alternative on available information
• Arrive the best choice for cost / risk

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Risk Analysis

Risk Analysis is used for the assessment of the hazards associated with an industrial or commercial activity and can be summarized by three questions given below.

• What can go wrong ? - Hazard Identification
• What are the effects and consequences ? - Consequences Analysis
• How often will it happen ? - Probability Estimation

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Risk –Benefit Analysis

• Assign Money Value to both risk and benefits
• Limits
• -Both risk and benefit are future value
• -Difficult to assign Money value to risk and benefit.

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Risk Benefit Analysis

RBA is being conducted for finding out answers for the following questions.

• Is the product worth for applying the RBA
• What are benefits
• Do they over weigh the risks

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Risk Benefit Analysis

Some other conceptual difficulties in RBA are as follows.

• Both risk and benefits lie in the future. So there is a chance for heavy discounting of future because the present low value of costs or benefits will not give a true picture of future distresses.
• Both have similar uncertainties but at the same time it is very difficult to arrive at expected values.
• What are all benefits to one person may be risks to other.
• Can't express risks and benefits in a common set of units.

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Risk Benefit Analysis

Reasons for RBA

• RBA is concerned with the advisability of undertaking a project.
• It helps in deciding which design has greater advantage.
• It assists the engineers to identify a particular design is better than the other.

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Ethical Implication of RBA

• RBA is also helpful to find answers to the following questions in an ethical way.
• When a person gives a right to impose a risk on another in view of supposed benefit of others.
• How do we consider the worst-case scenarios of persons exposed to maximum risks while they are receiving only minimum benefits.
• Are they provided with safer benefits.

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RISK BENEFIT ANALYSIS AND REDUCING RISK

• Personal Risk
• Public Risk and Public Acceptance
• Accounting Publicly for Benefits and Risks
• Incentives to Reduce Risk
• Some Examples of Improved Safety
• Liability

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Risk Avoidance

• Apply inherent safety concepts in design
• Create redundancy in protection
• Test systems for reliability
• Train operators
• Develop emergency plans
• Regular audit and drills to ensure preparedness

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CASE STUDY

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• Three Mile Island

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• Chernobyl

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Three Mile Island

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Three Mile Island

Problem arises because of these reasons.

• Not all eventualities (possibility) are foreseeable
• Even the most predicted problems have to be solved by error prone human designer
• Failure of Human operator to take the necessary rapid decisions during emergency.
• Lack of safe exits

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Three Mile Island

• Prior Warnings : Three Mile Island laboratory offered not only technical lessons but also the need for disaster planning and “Open Mind ness”, which means close examination of safety problems uncovered by rules. This requires an active support and concern on the part of the management.

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Three Mile Island

• Stephen Hanauer a government nuclear safety expert pointed out
• the poor performance record of values in nuclear power plants,
• the lack of proper analysis of field reports of values in nuclear power plants and
• the lack of proper analysis of field reports, which would help identify weak spots in design.

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Three Mile Island

• Deputy Director for licensing at the Atomic Energy Commission expressed that the frequency of serious and potentially catastrophic (disastrous) nuclear incidents supports that conclusion that eventually a major disaster will occur at a major generating facility. In spite of such warnings from the experts, there was lack of response for orderly emergency measures involving off-site populations and agencies.

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Three Mile Island

• James Creswell a reactor inspector for the Nuclear Regulatory Commission (NRC) discussed startling (surprising) similarities between the incidents that has occurred Davis-Besse during low power tests in September in 1977 and at Rancho Seco in California. A severe and sudden increase in heat has taken place in both the cases. The first one failure is because of the main feed water system and similarly the second one is because of faulty control signals produced from the control panel.

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Three Mile Island

• The accident at the Three Mile Island unit -2 Nuclear Power Plant in Pennsylvania on March 28,1979 was recorded as one of the most serious disaster in the history of nuclear industry. At 4 A.M. on March 28^th 1979 unit TMI – 2 was operating under full automatic control at 92% of its rated output. A regular maintenance work has been carried out on the polisher at that time. Some resin beads clogged the resin pipe from the demineraliser to a tank in which the resins is regenerated. In flushing the pipe with water, a little water backed up into an airline that provides air for fluffing the resin in the regeneration tank. However, that airline is connected to the air system that also serves the control mechanisms of the large valves. Thus, the valve closed unexpectedly.

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Three Mile Island

• The water flow interrupted in the secondary loop and booster pumps turned off. This caused the main feed water pumps and the turbine to shut down as well. In turn, an automatic emergency system started up the auxiliary feed water pumps. There was little outlet for the heat generated by the fission process in the reactor core because the turbine was inoperative. The pressure of the reactor rose to over 2200 pounds per square inch. This had opened up a pressure relief valve and signaling SERAM in which control rods are lowered into the reactor core to stop the main fission process.

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Three Mile Island

• The open valve succeeded in lowering the pressure. Its solenoid was deenergized. Contrary to control panel’s indication, the valve remained open. The pump could not supply the auxiliary feed water because block valves had been left closed after maintenance work done on them. Without feed water in loop, the stream generator boiled dry. Now there was no heat removal from the reactor except through the relief valve. Water was pouring at a rate of 220 gallons per minute. Even with the control rods shutting off the main fusion reaction, there would still be considerable heat produced by the contain radioactive decay of waste products.

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Three Mile Island

• One of the groups of pumps starts functioning automatically because of the loss of the water in the reactor. The operators started another pump to enhance the water supply for the reactor core. Now the full emergency core cooling system set in motion in response to low reactor pressure. Low reactor pressure can reduce the effectiveness of heat transfer from the nuclear fuel to the water by producing stream bubbles. The pressurizer is designed in such a way that it can keep the reactor water under pressure. The fluid level in the pressurizer is the only indication for measuring water level in the reactor.

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Three Mile Island

• The stream in the reactor vessel rises the fluid level in the pressurizer. The operators misinterpreted and shut down the emergency core cooling system. Then they proceeded to drain water at a rate of 160 gallons per minute from the reactor. Now, they were unaware of the water escaping through the open relief valve. The stream bubbles in the reactor water covered much of the fuel rods began to crumble. The chemical reaction between the stream and zircaloy produced hydrogen, which was released in to the containment structure where it exploded.

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Three Mile Island

• The situation became even worse when the shift operators had arrived. The relief valve was deduced to be open. Blocking valve in the relief line was closed. A general alarm was sounded soon after the radiation level in the container raised.

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Three Mile Island

• In the mean time, a pump was transferring drained water from the main containment to the adjacent building but not into the holding tank. Because of this there was air borne radiations in the control room to force evacuation of essential personals. The remaining technicians were forced to were facemasks.

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Three Mile Island

• At this juncture the operators decided to turn the high-pressure injection pumps along with the automatic system. The core was covered once more with water. After thirteen and half-hours the start of the episode the situation was brought under control.

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Three Mile Island

• The main cause of disaster is the lack of emergency preparedness at both the reactor site and evacuation planning centers. The cleanup operation showed that the radioactive water has been dominated and only one behalf of the 300,000 pounds of core debris has been removed. The expenditure of the clean up operation is rated as over a billion dollars. Three-Miles Island was a financial disaster.

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�� CHERNOBYL DISASTER:

At a Glance

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Introduction

• Chernobyl- small town in Ukraine near the Belarus border

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• 110 km north of Kiev (capital of Ukraine)

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• Nuclear power station of Chernobyl lies 15km to the northwest of the actual town of Chernobyl.

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• In 1986, the USSR generated 10% of the world’s nuclear power from only 46 reactors, producing 37 MW of electricity.

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• Still in their planning stages were another 34 reactors which would represent another 37MW of electricity.

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• By 1986, the year of the accident, four of the reactors at the Chernobyl Nuclear Power Station were the most modern RBMK- type.

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Map of Chernobyl and its surroundings, including the capital city of Kiev

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Reactor Analysis:

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• RBMK- Reactor Cooled by Water and Moderated by Graphite.

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• Uses nuclear fission process to release energy

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• Bombarding particle is neutron and target particle is Uranium

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• Soviet RBMK nuclear reactor uses graphite as the moderator.

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• Reactor consists of: reactor vessel, core and control rods

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Reactor Design

Layout of Reactors No. 3 & 4 at the Chernobyl Nuclear Power Station. Unit No. 4 is the one that was destroyed in the accident.

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Operation Of the Reactor:

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• As the reaction occurs, the uranium fuel

becomes hot.

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• Water pumped through the core in contained

pressure tubes removes the heat from the fuel

• Water boils into steam

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• Steam turns to turbines which spin electrical generators

• Water is cooled

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History of Accidents?

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• Before the 1986 disaster, Chernobyl was rated as one of the safest nuclear reactors .

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• A Soviet official was quoted as saying” the odds of a meltdown occurring at Chernobyl are 1 in 10,000 years”.

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• However during the trial of administrative staff of the plant in 1987, there had been numerous accidents and emergency shutdowns.

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The following is cited from the official court verdict of the trial:

“There were many unscheduled shutdowns because of mistakes by personnel. The causes were not properly investigated and in some cases they were covered up. Out of 71 technical breakdowns bet. 1980-86, no investigations into the causes was carried out in atleast 27 cases. Many cases of equipment failure had not been registered in the operation logs.”

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Time Line of Events:

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25^th April 1986:

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1:00 a.m- Reactors running at full power with normal operation. Steam power directed at both turbines of generators to observe dynamics of RMBK

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2:00 p.m-Under normal procedures of the test the reactor would have been reduced to 30% of power, but Soviet authorities refused to allow this due to need of apparent power elsewhere. So reactor remained at 50% for another 9 hrs.

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26^th April

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1:22 a.m- Operators thought that they were out of unstable conditions and decided to continue testing by blocking automatic shutdown on low water level and loss of both turbines.

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1:23 a.m- Remaining turbine was shutdown and the test was continued.

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Countdown to the Catastrophe

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1:40 a.m- Power in turbine began to rise gradually because of reduction in water flow and shutdown turbine, which lead to increased boiling point. Operator initiated manual shutdown, which lead to inc. in power.

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1:44 a.m- Disaster point- Reactor reached 120 times its full load power and radioactive fuel disintegrated which increased pressure and blew the entire shield apart!!!

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Emergency

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With the world’s greatest nuclear disaster underway, the fight to control the invisible killer was just beginning. Multiple fires, a reactor core on fire, citizens nearby, high radiation levels were all the ingredients of a huge disaster.

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Preventive Measures

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• Fighting the fire
• Sarcophagus
• Evacuation

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Destroyed Reactor no.4

The reactor is isolated by steel and concrete- Sarcophagus

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The Cause

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• Operator Over Confidence

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• Design Flaw

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• Safety System Inadequacies

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These causes led to the Chernobyl Nuclear Tragedy which had resulted in the several Local and Worldwide Effects.

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Future Plans:

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• To this date Reactor nos. 1 and 3 are still

functioning at Chernobyl.

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• Reactor no.3 had to be shutdown 5 years ago

after a fire broke out.

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• “This proves that the plant must be shutdown

quickly” said Kostyantyn Buzadhi of Greenpeace

Ukraine.

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• Officials promised to shutdown Reactor no.1 in

the plan to shutdown the entire power station.

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Professional Responsibility

• Internal
• Collegiality
• Loyalty
• Respect for Authority
• Collective Bargaining
• External
• Confidentiality
• Conflict of Interest
• Occupational Crimes

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• COLLEGIALITY

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• RESPECT

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• COMMITMENT

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• CONNECTEDNESS

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• CO- OPERATIONS

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AGENCY LOYALTY

• CONNECTED TO CONTRACTUAL DUTIES
• FOLLOWING LEGITIMATE AUTHORITY
• ALL CO OPERATIVE ACTIVITIES WITH ONES CO- WORKERS.

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Identification Loyalty

• Personal attachment
• Moral duties
• Positive attitude/ emotions towards organization

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AUTHORITY

• INSTITUTIONAL AUTHORITY:

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• ACQUIRED,EXERCISED & DEFINED WITHIN INSTITUIONS
• DEFINED BY ROLES & RESPONSIBILITIES
• EMPOWERMENT

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AUTHORITY

• EXPERT AUTHORITY:

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• KNOWLEDGE OF THE PERSON
• SKILLS AND COMPETENCE
• CHARISMATIC LEADERSHIP.

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Collective Bargaining

• Unionism

- Economic Interest of Members

• Professionalism

- Interest of Society and Employer

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CONFIDENTALITY�

• CONFIENTAL INFORMATION – KEEP SECRET
• PRIVILEGED INFORMATION
• PROPRITARY INFORMATION
• TRADE SECRETS
• PATENTS.

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CONFLICTS OF INEREST

• They are situations where professionals have an interest which if pursued might keep them from meeting their obligations to their employers or clients.

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• Could negatively impact the company & individual.

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Conflicts of Interest

• Actual - Weak Judgment
• Potential - Difference between

Bribe& Gift

• Apparent - Payment based on cost

on Design

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Causes of Conflicts of Interest

• Financial Investment
• Insider Trading
• Bribe
• Gift
• Kickbacks

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GIFTS & BRIBES

• BRIBES: Money & goods offered beyond the business contract.

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• GIFTS: small gratitude offered during the normal conduct of business.

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OCCUPATIONAL CRIME

• “Secret violating of laws regulating work activities”

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• Individuals espionage - Spying
• Price fixing - Cartelizing
• Endangering lives – Exposing to

Safety Hazards

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Professional Rights

• Rights by Virtue of being Professionalism
• Fundamental Rights

-To form Professional Judgment

and Express

- Refuse and refrain in unethical

activities

- Disagree on Professional Issues

- Warn and Cautions on Public

- Receive fair remuneration for the

Service

- Engaging in Professional Society

Activity

- Professional Conscience

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Negative Rights - Others not to inter- fare

Positive Rights - Management

support

Special Rights – Right of

Conscientious

Refusal

Right to Professional Recognition

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Employee Rights

• Right to disobey to do unethical activities
• Right not to be discriminated
• Contracted Employee right
• Choice of outside activity
• Privacy
• Right to due Process.

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Discrimination

• -Morally unjustified treatment to people

Preferential Treatment

-weak Preferential

Preferring members of traditionally discriminated over equally qualified.

-Strong Preferential

Preferring members of traditionally discriminated over better qualified.

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Intellectual Property Rights -IPR

• Creativity of Brain
• Forms

-Patents

-Trade Marks

-Geographical Indications

-Copy right

-Integrated Circuit

-Trade Secrets.

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Importance of IPR

• Provides Exclusive Right to Inventor
• Permit avoidance of Competitors
• Permits entry to Technical Market
• Generate steady income to Licensee

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Need for IPR

• To prevent Plagiarism
• To prevent others using it
• To support income generation.

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Whistle-blowing

Whistle-blowing: To convey information outside approved organizational channels to bring attention to a problem within the organization.

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Whistle-Blowing: Considerations

Evidence of potential harm to public is necessary.

Documentation

Consultation with colleagues

Moral obligations based on

...responsibility to society

...responsibility to one’s employer

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Whistle-Blowing: Considerations

Personal Liability

-”…most whistleblowers have suffered unhappy, even tragic fates.”

-”…generally it holds little promise as the best possible method for remedying problems, and should be viewed as a last resort.”

-Martin and Schinzinger, Ethics in Engineering

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Whistle-Blowing

Always the LAST RESORT, it indicates serious corporate culture problems

Can be internal as well as external

Definition depends on one’s point of view: (Martin and Schinzinger, pg 214)

“Whistle-blowing” - the act of a man or woman who, believing that the public interest overrides the interest of the organization he[sic] serves, publicly “blows the whistle” if the organization is involved in corrupt, illegal, fraudulent, or harmful activity (Nader, Petkas, and Blackwell, 1972)

Some of the enemies of business now encourage an employee to be disloyal to the enterprise. They want to create suspicion and disharmony and pry into the proprietary interests of the business. However this is labelled -industrial espionage, whistle-blowing or professional responsibility - it is another tactic for spreading disunity and creating conflict (Roche-GM chairman, 1971)

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Examples of problems that might warrant whistle-blowing

• Incompetence
• Criminal Behavior
• Unethical Policies
• Threat to Public Safety
• Injustices to Workers

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Moral Guidelines to Whistle-Blowing (ref. Richard T. DeGeorge)

It is morally permissible for engineers to engage in external whistle-blowing concerning safety:

1. If the harm that will be done by the product to the public is serious and considerable

2. If they make their concerns known to their superiors

3. If getting no satisfaction from their immediate superiors, they exhaust the channels available within the corporation, including going to the board of directors.

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Whistle-Blowing (cont)

In order for whistle-blowing to be morally obligatory however, DeGeorge gives two further conditions:

4. He [or she] must have documented evidence that would convince a reasonable, impartial observer that his [or her] view of the situation is correct and the company policy wrong.

5. There must be strong evidence that making the information public will in fact prevent the threatened serious harm.

(ref. Martin and Schinzinger, pg 217)

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Whistle Blowing Examples

• C-5A Cost overruns
• BART
• DC-10 Cargo door
• Challenger

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DC10 Cargo Door

• On June 12, 1972 A DC-10 left Detroit with 67 passengers, after reaching 12,000 ft, the cargo door blew off, collapsing floor and disrupting all hydraulic controls to tail section. Only the pilot’s skill and the light load prevented a disaster.
• June 27, 1972 Daniel Applegate, Director of Product Engineering for Convair, the fuselage contractor, wrote a memo to his supervisors detailing potential problems of cargo door. The problem was first recognized in Aug 69. The same thing had also happened in a ground test in 1970.
• Recognized design flaws - floor, latch

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DC10 Cargo Door (cont.)

• After the Detroit near-disaster, NTSB (National Transportation Safety Board) investigation revealed several problems and recommended immediate design changes. FAA did not follow NTSB recommendations. FAA director John Shaffer and Douglas President Jackson McGowan reached a gentleman’s agreement to voluntarily fix problem, but no further official action was taken.
• In July 1972, Three inspectors at Long Beach plant certified that Ship 29 had been modified (but it was not). Two years later, after leaving Paris, its cargo door blew off at 13,000 feet, killing 346 people.

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Why Did This Accident Happen?

• McDonnel Douglas was in precarious financial condition - trying to beat Lockheed L1011 to market
• Convair did not push too hard, since by contract, they may have been held liable for the costs of all design changes
• Engineers pressed the matter through normal channels to the highest levels within both companies, but did not take it any further, Standard operating procedure at McDonnell Douglas and Convair was for engineers to defer to upper management, even though they were aware of serious design flaws

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Were the engineers negligent?

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A Reasonable Care Model of Professional Responsibility

A person, S, is responsible for the harm he or she causes when his or her conduct fits the following pattern:

(1) as a member of a profession, S has a duty to conform to the standard operating procedures of his or her profession, unless those standards are lower than those that a nonprofessional would adopt in a given situation, in which case S has a duty to conform to the higher standard:

(2) at time t, action X conforms to the standard of reasonable care defined in (1);

(3) S omits to perform X at time t,

(4) Harm is caused to some person, P, as a result of S’s failure to do X.

(ref. Curd and May, pg 15)

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Summary

• Where you draw the line is your choice
• Corporate ethics begins with each person
• You can be held personally and legally responsible for your professional actions
• It is important to understand your company’s attitude toward ethics - it should be a factor in your choice of employer

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Is Whistle-Blowing Justified?

Class Discussion

Harry and the silent salesman (pg 222, Martin and Schinzinger)

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Edgerton case, (pg 223, Martin and Schinzinger)

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