The Need for Change¶
President's Commission on the Accident at Three Mile Island. (1979). The Need for Change: The Legacy of TMI — Report of the President's Commission on the Accident at Three Mile Island.
Cited by¶
2 citations across 2 artifacts.
Each citation links to the sentence it supports in the citing article.
Domain-specific¶
- Alarm Fatigue
- … through habituation and base-rate collapse, producing a rational-but-pathological equilibrium of disregard — genuinely recurs as a co-instance*, not a resemblance, in aviation (warning blindness; cockpit alert overload, with Three Mile Island's control-room alarm overload a canonical case in nuclear operations
This sourceThe Kemeny Commission's finding that more than 100 alarms sounded in the first minutes at Three Mile Island with no way to suppress the unimportant ones.
SupportedVerified against the source
- … through habituation and base-rate collapse, producing a rational-but-pathological equilibrium of disregard — genuinely recurs as a co-instance*, not a resemblance, in aviation (warning blindness; cockpit alert overload, with Three Mile Island's control-room alarm overload a canonical case in nuclear operations
- Organizational Influence Failure
- Aviation — the framework's birthplace: carrier-level training/schedule/maintenance-contracting decisions, just-culture-versus-blame norms, and fatigue and minimum-equipment policy. Healthcare and patient safety — hospital staffing ratios, formulary and EHR-vendor choices, and on-call culture as the apex decisions that stage downstream patient-safety events. Nuclear and process safety — plant-management procedure-revision cadence, maintenance-deferral, and training-refresh decisions (the layer the post-TMI literature isolated as decisive)
This sourceThe TMI Commission finding that the fundamental problems were people-related - operator training and procedures - rather than equipment.
Supported in partVerified against a saved copy of the source
“became clear that the fundamental problems are {{{people-related}}} problems and not equipment problems.”
- Aviation — the framework's birthplace: carrier-level training/schedule/maintenance-contracting decisions, just-culture-versus-blame norms, and fatigue and minimum-equipment policy. Healthcare and patient safety — hospital staffing ratios, formulary and EHR-vendor choices, and on-call culture as the apex decisions that stage downstream patient-safety events. Nuclear and process safety — plant-management procedure-revision cadence, maintenance-deferral, and training-refresh decisions (the layer the post-TMI literature isolated as decisive)
Verification¶
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Registry ID ref:892fdfec7984 · see in the full table