[nine_k]

It's not the litter, it's the typo.

It was not sufficient to just write "inorganic". Given the seriousness of possible consequences, some redundancy should have been added. E.g. "inorganic mineral-based kitty litter can be used; organic kitty litter is not acceptable". A few more words would have prevented an actual nuclear incident.

[ortusdux]

From the link:

In May 2012, Los Alamos published a white paper titled “Amount of Zeolite Required to Meet the Constraints Established by the EMRTC Report RF 10-13: Application of LANL Evaporator Nitrate Salts.” In other words, “How much kitty litter should be added to radioactive waste?” The answer was about 1.2 to 1, inorganic zeolite clay to nitrate salt waste, by volume.

That guidance was then translated into the actual procedures that technicians would use to repackage the waste in gloveboxes at Los Alamos. But something got lost in translation. As far as investigators could determine, here’s what happened: In a meeting in May 2012, the manager responsible for glovebox operations took personal notes about this switch in materials. Those notes were sent in an email and eventually incorporated into the written procedures:

“Ensure an organic absorbent is added to the waste material at a minimum of 1.5 absorbent to 1 part waste ratio.”

[rob74]

That's... a shocking level of lack of professionalism. I mean, as a software developer, when someone tells you to implement something, do you do it just based on the notes you took while your project manager discussed the task with you, or do you read the actual Jira ticket and use the information you (hopefully) find there? And we're (mostly) not writing software that handles nuclear waste...

[structural]

Something to consider is that in a secure environment like LANL, and especially for a non-standard or one-off process, it's likely that there is no computer system that everyone has access to with all the information.

It would not be unusual for the person being told to write the process document to be brought into a room with a notebook, be shown written or electronic materials in the room, take notes in a provided notebook, have that notebook be handed over after the meeting for a (non-technical) security review, then receive the notebook pages some days/weeks later and have those notes be what is used to develop the document. Security culture is good for security but bad for error-free processes involving people.

[HeyLaughingBoy]

Very often the notes contain a lot more information than the ticket. Tickets are often written by people who barely understand the problem.

[touisteur]

And from the state of note-taking and summarizer bots on audioconferences it's going to become potentially worse. The number of times I've had to correct negations in the results of several of those applications in the last year or so... to add to annoyance of either sifting through the emmms and errrr, or through the summarizers' annoying tone...

[fsckboy]

so you're saying this was really an unclear incident?

[nine_k]

Jokes aside, aren't most incidents a result of lack of clarity, ignored and creatively reinterpreted enough times?