Dreaming About Learning Faster

Added on Jun 11, 2015

On 9 May 2015 at approximately 5:50pm ET a Notice of Unusual Event (NUE) occurred at Indian Point Energy Center Unit #3.

Healthcare Safety

Indian Point Energy Center, in Buchanan, N.Y., is home to two operating nuclear power plants, unit 2 and unit 3, which generate approximately 2,000 megawatts of electricity to supply about 25 percent of power used annually in New York City and Westchester County.

A transformer failure resulted in a fire that was extinguished at approximately 9:03pm ET. Indian Point, Entergy and the Nuclear Regulatory Commission (NRC) are all investigating the transformer failure and any subsequent concerns related the discharge of the transformer’s dielectric fluid.

I learned of this event the following morning from an email sent by Craig Clapper, Founding Partner and Chief Knowledge Officer at HPI. He told our team:

    “NUE is the lowest severity of the four event classification systems. All 100 of the nuclear plants in the US will already know of this event as they start work this morning, and they will all be thinking about what – if anything – they should be doing differently with their transformers. Indian Point 3 will need to identify root causes and actions to prevent recurrence before they restart.”


I read that paragraph multiple times and thought about the potential learnings for healthcare. Several thoughts came to my mind. Imagine a world:

  • • Where all hospitals were notified within hours regarding serious safety events
  • • Where hospitals freely shared their events without fear of discoverability and litigation
  • • Where the right people learn of a serious safety event within hours and we assemble a team to start working on it


I’ve since found information regarding the event on both the Indian Point and NRC’s websites - all public information (see links below). We’ve made some strides in healthcare regarding transparency, and we still have a long way to go.

Questions to consider:

  • 1. How can we become better in sharing vital information regarding safety events within our own walls in a timely manner?
  • 2. What will it take for transparency of events to become a national expectation?
  • 3. Do you think we will ever see the level of sharing seen in Nuclear Power and Aviation?


I think it’s possible. “You may say I’m a dreamer, but I’m not the only one.” – John Lennon


Indian Point Website: http://www.safesecurevital.com/#

Latest NRC Communication re: Indian Point Event: http://www.nrc.gov/reading-rm/doc-collections/news/2015/15-024.i.pdf


Photo Credit: "Indian Point Nuclear Power Plant" by Tony - https://www.flickr.com/photos/tonythemisfit/2755502911/ Licensed under CC BY 2.0 via Wikimedia Commons