Lessons learned from nuclear accident can improve creches
Published 04/06/2013 | 17:00
The Three Mile Island nuclear power plant accident in 1979 had the greatest impact on nuclear regulation of any single event in history. The main pumps feeding cooling water into the reactor stopped running, preventing the steam generators from removing heat. This led to half the reactor core melting down. Three Mile Island could have been a Chernobyl-level nuclear disaster. It led to huge changes in how nuclear plants are regulated internationally.
Once the physical damage was contained, investigators tried to figure out how the pumps had failed. The first line of inquiry was to look for human error, a failure to follow procedures, or inadequate regulation. In fact, almost no slips were made. Every one of these highly paid professionals took nuclear safety very seriously and followed the rules to the letter, yet still there was a near catastrophe.
It turned out that those working in the nuclear power plants had become rule-following automatons, unable to see where the real risks lay while they blindly followed procedures set down for them to comply with.
Following Three Mile Island, the nuclear sector made a move away from simply inspecting compliance of rules to evaluating risk-management systems. The goal was to establish if senior managers had the "risk-analysis intelligence" to deal with unforeseen events.
Joseph Rees details this remarkable change in his 1994 book, 'Hostages of Each Other: The Transformation of Nuclear Safety since Three Mile Island'. Rees shows that while it is important to impose rules to constrain risky behaviour in all aspects of life, looking to the broader issues makes more sense in the long run. He also detailed how personal incentives were used to ensure the risk managers treated these risks as if they were bearing them themselves.
Hammurabi was a Babylonian king who died around 1750 BC. His laws have stood the test of time, and many of them involve building incentives into them to ensure orderly conduct. Hammurabi would have had no problem with including incentives to ensure high levels of service. Here's rule 229: "If a builder has built a house for a man, and has not made his work sound, and the house he built has fallen, and caused the death of its owner, that builder shall be put to death."
You can't imagine there would have been all that many Priory Hall-type episodes in Hammurabi's day.
This column has highlighted childcare issues for several months. In fact, several years' worth of exposés have shown Ireland's record on inspections and regulation of childcare facilities has been lax. Our children are at greater risk than necessary in childcare facilities. This is not acceptable, and yet for more than seven years we have allowed lapses in regulations to exist.
We are told there will be an effort exerted by the relevant agencies to change the behaviour of childcare facilities to certain pre-defined conditions set down by those agencies. Things like numbers of cots and fire extinguishers will be monitored more closely, as will the qualifications of staff within the childcare facilities. It is important, of course, to have an element of standard setting, information gathering and monitoring, as well as imposing penalties when childcare facilities break these minimum standards.
Safety is, of course, the priority. But the overarching goal is to change the behaviour of the people running and working in our creches and childcare settings – the purpose for which regulation is normally used. We want to influence individual and firm-level behavioural patterns to make sure childcare workers treat our children as well as they possibly can.
We want the softer elements of childcare as well. Insofar as is possible, every parent would like their child to get the kind of care, attention and education that they themselves would provide if they were available. Every parent wants their child to be included, to be hugged and made feel they have value. But can we tell any of these things by counting fire extinguishers and numbers of cots and numbers of certificates?
We take risks when we put our kids in our cars and drive them on the roads, when we take them for a walk and when we place them in the care of others. There's no way around that – it's part of life. Mistreatment of a child, or a class of children, is a risk we take when we put them in the care of others. We want to make that risk as small as humanly possible through training, transparency and regulation.
I suggest we use Three Mile Island and Hammurabi as our guides when thinking about resolving the problems we see in childcare.
First, our inspectors should not look blindly at health and safety-type regulations alone. Yes, fire extinguishers are important, but so is seeing the childcare workers hugging the children, watching them work with the children for an hour or more, getting a sense of the "vibe" of a room of children and understanding the support structures in place for the workers. This will help them understand the "meta risks" at play in the childcare environment.
Second, it was clear from RTE's 'A Breach of Trust' programme that management structures had broken down. Staff were not trained or supported, and a culture where regulations were flaunted flourished. Managers should be entrusted and empowered to support their staff. When the staff fail in their care and education of our children, ultimately the manager personally must suffer the consequences.
These are simple steps that cost very little to implement. What are the odds they won't be?
Stephen Kinsella lectures in economics at the University of Limerick