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ready for takeoff thank you so much for being  here my name is Nicholas means   I am the lead of the engineering team at Sim  where we're building tools to create engine   for engineering teams to create and orchestrate  slack-based access and authorization workflows   so if you've got production system access  challenges come find me we should talk I also   co-host a podcast called managing up if you're  into managing stuff management stuff you might  
be interested in it check it out at managing up  dot show today though I'm here to tell you a story   dotted along the coast of Japan usually a  significant distance from the water are Stones   like this one left there by Anonymous members of  previous generations and they all say something   very similar a home built high is children's  relief remember the disastrous giant tsunami  
do not build homes below here now Japan is  one of the most seismically active countries   on Earth built on the Pacific Ring of Fire  these Stones make it obvious that they are   also no stranger to tsunamis massive ocean waves  driven by earthquakes under the sea so given the   risk of tsunamis you might be surprised by  this map of nuclear power plants in Japan   every single one of them is right on  the coast why is that well when you  
picture a nuclear power plant what Pops  to mind it's probably something like this and credit to The Simpsons this actually is  a fairly accurate rendering of a two unit   pressurized water nuclear power plant but the  thing in this picture that you probably most   closely identify with nuclear power is the  two hyperboloid cooling towers Standing Tall   over the rest of the plant now the funny  thing about this is that there's nothing   inherently nuclear about them every thermal  power plant nuclear fossil fuel needs a source  
of cooling there are plenty of non-nuclear  power plants that use hyperbola towers and   plenty of nuclear plants that use other kinds  of cooling like these mechanical draft arrays   the post-war economic boom in Japan meant that  by the 1970s Japan was starving for electricity   we need to build a bunch of nuclear power plants  in a hurry and on a budget one of the best ways   to reduce time and cost is to build them on large  bodies of water to use the ocean as a giant heat  
sink so you don't need cooling towers at all and  that's what Japan did over and over again one of   those plants on the sea with no cooling towers  is Fukushima daichi a six unit boiling water   nuclear power plant with a generating capacity  of 5.3 gigawatts owned and operated by the Tokyo   Electric Power Company or tepco it's located  right on the Pacific coast in Northeast Japan   the reactors at Fukushima daichi went online  between 1971 and 1979 all of them boiling  
water reactors designed by General Electric in  the United States unit 1 is a slightly smaller   older design than the rest of the fleet  unit 6 is a slightly larger newer design   March 11 2011 started like any other day at  the plant units one two and three were all   running as they say in the nuclear industry  hot straight and normal running at full   power generating electricity unit 4 was offline  being refueled units five and six had both just   finished being refueled and were undergoing  testing in preparation for for restarting  
but off the coast of Japan and the Earth's  crust trouble had been brewing for more than   a thousand years as the Pacific Plate continually  subducts under the akhotsky plate that tohoku and   the rest of Northeastern Japan sit on potential  energy is built up like a spring being compressed   on March 11 2011 at about 2 46 in the  afternoon that potential energy finally   overcame the friction between the plates holding  it back and became kinetic energy in the form of  
a magnitude 9.1 earthquake the Epson was about  45 miles off the coast but subduction zone Mega   thrust Quakes like this one typically involve a  rupture along hundreds of miles of fault line in   this case the fault line that ruptured roughly  parallels the northern coast of Japan the force   of this rupture was such that Northern Japan  moved about eight feet closer to North America   and the tilt of the Earth's axis shifted somewhere  between 6 and 10 inches we're not really sure  
it was the most powerful Quake to  ever strike earthquake prone Japan   when the shaking started masal Yoshida director  of Fukushima daiichi was in his office processing   some of the paperwork that was ubiquitous in  the tepco bureaucracy Yoshida kept expecting   to say the shaking to taper off but it just got  stronger for six long minutes the ground shook   when it finally stopped he knew there would be  much to be done so he threw on his hard hat ran  
out of his office he fought his way through  this mess right outside his door and headed   towards the plant's earthquake proof Emergency  Response Center the control room for units one   and two was in disarray right after the quake as  the shaking stopped The Operators immediately ran   to the panels and started figuring out the state  of the plant calling out various measurements to   akua azawa the shift supervisor in charge of units  one and two that day they were able to quickly see   that the plant's automated emergency systems  had done exactly what they were supposed to do  
now to understand what happens next you need  to know a little bit about how nuclear reactors   work so let's do a crash course the heart of  any thermal power plant is the heat source in   a nuclear reactor it's the uranium fuel rods that  create the heat generating nuclear chain reaction   the fuel rods are contained in a pressure vessel  and surrounded by water that in a Boiling Water   Reactor boils to steam at the top of that  pressure vessel and there are also Neutron   absorbing control rods that can be inserted in the  core to slow or stop the chain reaction as water  
boils to steam at the top of the reactor vessel  it expands and the energy from that expansion   turns a Turman connected to a generator this  is how the plant actually generates electricity   as after the steam turns the turbine it's directed  into a condenser where it turns back into liquid   water and then a circulation pump pumps that  liquid water back into the Reactor Core this   is crucial because water constantly boiling  to steam at the top of the reactor pressure   vessel has to be continually replaced  to keep the fuel rods from overheating  
and Fukushima daichi like most nuclear plants  there are sensors to detect Earth movement   when there's an earthquake the reactor control  system automatically scrams the reactor putting   the control rods all the way into the core and  instantly halting the nuclear chain reaction   this happened exactly as it was supposed to in  all three active reactors but the fuel in the core   of a nuclear reactor gets so hot that cooling  circulation must be maintained for days after   shutdown to continue carrying this Decay heat  away from the fuel so the fuel rods don't melt  
only once that cooldown has happened has the  plant reached a safe state of cold shutdown   that means the reactor's circulation pumps must  be kept running even though the core is shut down   and that's a problem when a giant earthquake  has severaged your plant's connection to the   electrical grid thankfully the plant had redundant  answers to this situation first each reactor has   two enormous diesel backup generators just one  of which provides adequate energy to maintain  
circulation through the core these generators  had all started automatically as soon as the   plant lost its grid Connection in case in  case the generators failed each control room   also had a bank of lead acid batteries to power  instrumentation and control valves for several   hours second each reactor had a passive cooling  mechanism that would function without any external   power at all in unit 1 that took the form of an  isolation condenser it was a large tank of water   open to the atmosphere Steam from the reactor  pressure vessel could be directed through a heat  
exchanger in the isolation condenser where  it would turn back into water and Flow by   gravity back into the pressure vessel with the  water in the isolation condenser boiling off to   steam in the atmosphere to release the Heat the  isolation condenser could passively cool unit one   for three days before requiring more water to  be added without any human intervention at all   the slightly newer units two and three because  they're larger have a different passive cooling   system the Reactor Core isolation cooling system  or rixi for short the rixxy is a more complicated  
system but the basics are that the steam from  the reactor pressure vessel drives a pump that   replenishes the water in the Reactor Core it  can be topped up from an external tank if the   water level drops when the backup generators  kicked on at Fukushima daichi these passive   cooling systems all kicked into gear as well at  this point despite being without power from the   electric grid the plant was well on its way to a  controlled shutdown everything was well in hand when the first tsunami warning went  out a few minutes after the Quake the  
initial prediction for the Fukushima area  was just around 50 centimeters 18 inches   that would later be revised several times but  never beyond the plant's 19-foot tall sea wall   they made a precautionary announcement over  the plant's PA system that there was a tsunami   warning and that workers should move to Higher  Ground just in case but that was the extent of   their preparations in reality the largest of  the three tsunamis heading towards the plant   was more than 40 feet high and it  was moving at 100 miles an hour
when it arrived the operators in the windowless  control room had no idea they were shocked when   one of the operators announced a new  critical alarm at 3 37 PM the diesel   generators have tripped a few seconds later the  overhead lights in the control room went out   then slowly randomly panel by panel  their instruments all went dark   the constant warbling of alarms from the  unhappy plant was replaced by an eerie silence   a few seconds later izawa broke the Silence by  shouting station blackout they had no electricity  
at all a situation never considered realistically  possible in all of their emergency preparations   the reactors at Fukushima daiichi are located  on the 10 meter level 10 meters above sea level   the huge diesel backup generators along with  the power switching equipment and lead acid   backup batteries were all in the basement of  the auxiliary building on the four meter level   when the tsunami arrived and inundated their sea  wall they were all destroyed The Operators found  
themselves trying to operate three nuclear  reactors that just minutes before had been   generating over two gigawatts of power with no  instrumentation and no remote valve controls   their immediate concern was unit one the operating  manual for unit 1 said that to protect the   reactor's pressure vessel the reactor's cooldown  rate couldn't exceed 55 degrees Celsius per hour   about 20 minutes after the Quake The  Operators realized that it was cooling   too fast and so they'd begun cycling the  isolation condenser in and out of service  
they had just cycled the condenser back off at  3 34 pm three minutes before they lost power   the ritzy systems in unit two and three would  keep them under control for the time being but   unit one because of unlucky timing was completely  without Cooling without coolant circulating carry   heat away all of the water in the core will  boil the Steam and this causes a couple of  
things first without cooling the nuclear fuel  rods will eventually get hot enough to melt   second because water expands when it turns to  steam the pressure in the pressure vessel Rises   if pressure gets high enough it will eventually  turn into a giant steam bomb and explode spraying radiation into the environment  now given fukushima's location that could   make Tokyo uninhabitable for decades that  fact was in the back of everybody's mind  
there are a few things they needed to do  to get unit 1 back under control and they   started working on them all at the same  time first they knew the instruments in   the control room would work under DC power  so while one team began looking at wiring   diagrams to figure out how to how to hook  up electricity to all their instrumentation   another team went out and began harvesting car  batteries from the cars parked around the site   well they worked on that another team began  working on figuring out how to get unit get water   into the core of unit one of the first things that  plant director Yoshida had done when the tsunami  
hit was to request fire engines from two nearby  Japan self-defense floor spaces now this wasn't   in the plant's emergency operations manual but  Yoshida predicted correctly that they would need   some way to pump water and fire engines were the  first thing that came to mind meanwhile katsuaki   hirano had just arrived at the unit one control  room he was a shift supervisor from a different   team he wasn't scheduled to work that day at all  but he had made his way to the plant to help as  
quickly as he could after the earthquake he had  the idea of using unit one's firefighting pipe   Network to Route water to the Core he led multiple  Expeditions into the dark reactor building   to manually turn the five valves necessary to  Route water from the fire pipes into the core   ano and a partner returned from their final  Expedition around 9pm by 11 pm radiation levels   at the reactor building airlock were so high that  further entry was prohibited by Yoshida so it was  
fortunate that hirano's expedition was one of  the first things that the operating crew did   the plant had three fire engines on site one  of them had been destroyed by the tsunami   a second couldn't get to unit one because of  tsunami damage to roads the third however was just   behind an electronic security gate at unit three  but electronic Gates don't work with the power out   by around two in the morning they finally  broken the lock on the security gate moved   the fire truck into place and had begun  injecting water into the core of unit 1.  
unfortunately the water injection they were  able to accomplish was very slow because of   pressure in the reactor vessel once they worked  out how to hook a hook up the scavenged car   batteries to the instrumentation and  control room they found that pressure   in the pressure vessel was significantly  elevated around two atmospheres of pressure   the only way pressure this high would have been  possible was if the fuel had begun melting down   so relieving the pressure and getting more water  in was absolutely critical thankfully Yoshida had  
anticipated this as well and was already working  on the necessary permissions to conduct event   now this is exactly what it sounds like venting  likely radioactive Steam from the pressure vessel   of the reactor into the open atmosphere it was it  was a worst case measure to try to save the plant   any atmospheric release of radiation  required government permission and that   permission needed to come from this man  naoto Khan the prime minister of Japan   as soon as an emergency had been declared at  the plant tepco sent a liaison to Khan's office  
so he had already been briefed on the rising  pressure at unit one he readily gave permission   for the vent as soon as the five kilometer  evacuation Zone around the plant was evacuated   a process that was already underway at the plant  izaw and his team had been working feverishly and   rapidly deteriorating conditions to figure out how  to vent the reactor radiation levels were now high   enough in the control room being there required  wearing full face masks with charcoal filters   if radiation was this bad in the control room it  would be terrible and dangerous in the reactor  
building they needed to figure out a way to vent  the plant that would have staff in and out as   quickly as possible back in tokyocon had finished  his middle of the night emergency press conference   to announce the vent and he was livid it was  four in the morning he'd given us permission   to vent hours ago why the hell hadn't they vented  unit one yet did they not know what was at stake   the tepco yet liaison in his office had explained  the challenges the staff of the plant were facing  
but Khan decided he needed to find  out for himself what was going on   so by 5 30 in the morning the day after  the earthquake the Prime Minister and   his Entourage ran a helicopter on their  way to Fukushima daiichi at the Fukushima   Emergency Response Center there was panic and  frustration over Khan's visit Yoshida and his   staff were now working feverishly to vent  unit one and now they had this to deal with on top of that they had another problem to solve  they were running short of protective equipment  
and now that the pre the PM and his Entourage were  coming they had to outfit them as well with their   dwindling stocks every time someone entered the  radiation shielded ERC the face mask that they   were wearing had to be discarded because as  soon as the seal with their face was broken   it was contaminated it was decided that Khan  would land at a nearby sports field and that   he and his Entourage would be brought as close to  the door of the ERC as possible in a mini bus so  
that they wouldn't need to waste Emergency  Equipment on them it was a clever solution   tepco VP takaimuto was among the party to greet  Khan's helicopter when it landed in Fukushima   Muto remembers offering kana's standard Japanese  greetings very formal along the lines of it's   very kind of you to come sir now I'm sure he  didn't feel this way but that's what Japanese   etiquette dictated that you said to the  prime minister in a situation like this   Khan quickly responded why the  hell haven't you vented yet  
he proceeded to yell at Muto for the entire  bus ride to the Emergency Response Center   remembers Khan saying repeatedly that he just  wanted to know what the problem was but then   not listening at all he seemed to only want to  complain that staff weren't doing their jobs   when Yoshida and Khan met in the ERC Khan's  first words to him what the hell is going on   rather than Fight Fire with Fire Yoshida  calmly explained the situation in detail   and as he talked Khan seemed to settle finally  Khan asked well when are you going to get the  
vent done more than anything else you must get the  vent done Yoshida responded calmly again we are of   course doing everything we can we have a Suicide  Squad preparing to enter the radiation field now   hearing that there were people willing to  risk their lives to conduct the dangerous   event operation seemed to end the discussion  the actual meeting had lasted 20 minutes   asawa's crew had identified a pathway to venting  that would require only require opening two valves  
the valves were in two different areas of the  reactor building so they would send two teams   of two into the radiation field under Japanese law  workers are allowed a maximum of 100 millisieverts   of radiation exposure during an emergency so  everyone put on a personal dissimeter alarm like   this one and set it to go off at 80 millisieverts  agreeing to turn back immediately if it went off   the first crew made their way to their valve on  the second floor of the reactor building it was   huge awkwardly placed at the end of a catwalk hard  to turn but they got it done and we're back to the  
control room in 11 minutes without coming close  to the the 80 millisievert alarm the second Cruise   valve was in a much more precarious position to  help us understand here's a photo of an under   construction Mark 1 containment structure the  thing represented in this diagram from earlier   their valve was in the basement of the  reactor building if there had been core   damage it was likely that melted fuel would be  sitting at the bottom of the pressure vessel  
creating an intense radiation field at the  bottom of primary containment as they made   their way into the basement the handheld radiation  meter They Carried was bouncing between 900 and   1000 millisieverts per hour roughly enough to  give them their Max dose in about 10 minutes   when they saw the meter stick at a thousand  millisieverts per hour the max that it could read   they had to turn back there was no way to  know how strong the radiation Fields they   were walking into were with their meter maxed  out when they got back to the control room  
they found that they had received a doses  of 89 and 95 millisieverts respectively   they were the first two workers to dose  out and have to be evacuated from the site   nearly 10 in the morning and the event still  hadn't been carried out the operators had gone   from elated at the success of the first  crew to despondent at the situation the   second crew encountered they didn't give up  there had to be a way to vent it one group   worked to see if a portable air compressor  could remotely operate the pneumatic valve  
while another tried to find a different route  to the valve at two in the afternoon the reactor   pressure vessel was up to eight atmospheres  of pressure about two times its rated strength   things were getting desperate the second crew  was just getting ready to make a run for the   valve determined to open it no matter what  the cost when they got a call from the ERC   white smoke was coming out the top of  the unit one and two shared event stack   slowly pressures in the reactor pressure  vessels started to drop they must be venting  
there was no way they could know for sure  without instrumentation but the attempt   to open the valve pneumatically must have  worked they felt a tremendous sense of relief   that relief would last for about an hour this  is what an off-site monitoring camera saw at   3 36 pm on Saturday March the 12th workers  scrambled upon protective gear to figure out   what had happened their initial fear was that  venting the reactor was too little too late and   the reactor pressure vessel that just exploded  but thankfully that wasn't what had happened
this is what a fuel bundle looks like for a  Boiling Water Reactor a given reactor would have   several of these bundles arranged in its core for  optimal reactivity most of the tubes you see here   are the actual fuel rods made of zirconium  alloy and filled with uranium fuel pellets   now zirconium is the metal of choice for this  because it's very corrosion and heat resistant   while also being essentially transparent to the  neutrons that sustain the nuclear chain reaction   as the core gets hot enough to melt it though  it's corrosion resistance runs out and it starts  
rapidly oxidizing and a reactor pressure vessel  filled with steam the sudden oxidization reaction   rips the surrounding water molecules apart forming  zirconium oxide and hydrogen gas which is very   flammable as the smoke and debris settled this is  what they saw given the shaking of the earthquake   and the significant over pressurization of the  reactor's primary containment it's likely there   were plenty of places the hydrogen created by the  Meltdown could have slipped through it accumulated  
at the top of unit 1's containment building  and all it took was one Spark the explosion   blew radioactive debris across the site it also  caved in a door and an air conditioning intake at   the Emergency Response Center contaminating the  one relatively radiation free space remaining   on the site the work of keeping units two and  three from melting down got that much harder   and circular the situation at unit three  was getting pretty critical the rixie had  
been passively cooling the reactor since the power  loss but heat was starting to build and they were   running out of fresh water on site Yoshida made  the call to use fire trucks to begin injecting sea   water they've been trying to avoid this because  they were still hoping to restart their reactors   someday and the salt in the sea water would ruin  the reactor meaning it could never generate power   again but they had to keep it from exploding that  was the priority back in Tokyo prime minister Khan  
heard that they were considering sea water  injection and demanded that they not do it   one of his small group of technical advisors  had mentioned a non-zero chance that the salt   in the seawater might cause the reactor to start  reacting again to become critical in reality the   chance was minuscule and an exponentially  smaller risk than a reactor explosion   Masala Yoshida had no intent of complying before a  video conference with tepco execs in Tokyo he told   his staff if they order me to Halt seawater  injection I will relay the order to you so  
that they can hear me you are not to respond  and you were not to stop seawater injection   it's our only chance unbeknownst to them core  damage at unit 3 had already occurred and if   they had stopped the seawater injection it might  well have exploded the next day unit 3 would   experience a hydrogen explosion just like unit  one unit four which wasn't even running at the   time of the earthquake would go on to explode as  well from hydrogen gas suspected to have leaked in  
from unit 3 via their shared vent stack they later  later learned that unit 2 had experienced core   damage as well and it likely avoided a hydrogen  explosion only because its reactor building was   damaged enough from the other two explosions to  vent the hydrogen instead of letting it accumulate   you can see units one through four in this photo  three of the four exploded three of the four in a   state of partial meltdown at this point radiation  levels at the site were making it hazardous to  
walk from building to building with staff running  everywhere they needed to go wearing heavy   protective gear so late in the evening of the 14th  Yoshida made the difficult decision to evacuate   most of the staff to Fukushima daini daiichi's  sibling plan a few miles away and only keep a   volunteer Skeleton Crew on site Yoshida didn't  allow anyone under 45 years old to stay because   people under 45 might still have children and  radiation poses more danger to them those over 45  
were free to leave as well if they wanted nobody  was forced to stay everyone who chose to stay knew   that there was a significant chance they'd suffer  dangerous radiation exposure possibly even die   but they felt the responsibility of the  rest of Japan to ensure that the plant   didn't cause wider contamination in the end  there were 68 plus Yoshida left at the plant   this group would be referred to  by the media as the Fukushima 50.   back in Tokyo prime minister Khan heard that  conditions of the plant were deteriorating  
and shockingly the tepco planned to abandon the  plant they can't do that it would surely explode   furious at the news Khan calls a middle of the  night meeting the tepco liaison a Khan's office   quickly clarifies the misunderstanding that  there's no intention of abandoning the plant   just evacuate non-essential personnel but it  doesn't matter Khan is finished at this point   he uses his authority to create a joint  response office with himself as the lead   taking over control of the response at Fukushima  from tepco despite knowing that there was never  
any intention to abandon the plant Khan  carries on like there was in the internal   video conference announcing the change if things  go on like this Japan is done for abandoning the   plant is Unthinkable you must risk your lives on  it if necessary if you abandon the plant tepco   will be destroyed you can run but you'll never  get away these were his words to a room full   of people who had just decided to sacrifice  their lives if necessary to save this plant  
at this point masal Yoshida had had enough  at the front of the room video conference   cameras still running Yoshida stands up turns his  back on the prime minister and lowers his pants he makes it look like he's just tucking his  shirt back in but everyone in the room knows   what he's really doing in Japan's formal business  culture turning your back on a superior is a huge   etiquette faux pas but Yoshida took  it exponentially further than that
now as the plant slowly came further and  further under control and danger became   less evacuated workers came trickling back in  to help it would take the better part of the   year but finally on December 16th tepco  declared cold shutdown at Fukushima all   reactors were below 100 degrees Celsius and all  radiation leaks had been substantially contained   this photo from earlier this year shows  the condition of the plant today a tank   farm sprang up around the plant to contain all the  contaminated water unit 1 and 2's buildings were  
able to be repaired but new containment structures  had to be built around units three and four   decommissioning work has begun and will likely  take the next 30 to 40 years to complete   in the history of new commercial nuclear power  generation there have only been five reactor   meltdowns three of these were at Fukushima to  fully understand the severity of the accident   let's put it into context by comparing the amount  of radiation it released into the environment   the first commercial reactor to partially melt  down was at Three Mile Island in Susquehanna  
Pennsylvania Islands contained Hydro hydrogen  explosion and subsequent venting released   approximately 626 gigabyte rolls  of radiation into the atmosphere   Fukushima daichi with its three partial meltdowns  and three uncontained hydrogen explosions is   estimated to have released 780 petabek rolls of  harmful radiation Three Mile Island is represented   as a one pixel dot here I promise it's there but  the correct side on this slide would actually  
be a circle 6 10 millionths of a pixel across  that's how much larger Fukushima was to through   Mile Island but compared to the largest nuclear  accident of all time Fukushima looks pretty small   Chernobyl a Soviet rbmk reactor designed famously  with no containment of any kind had exploded and   there was nothing to keep it from going straight  up into the atmosphere to the tune of 5.2  
exobecerals around seven times as much radiation  as Fukushima it was a huge accident but let's   say that the operators at Fukushima had failed to  establish Cooling and relieve the growing pressure   in their containment vessels and all three running  units at Fukushima experience steam explosions   an uncontained failure at all three Fukushima  daiichi units would have released at least   7.5 exabec rules but because fukushima's  reactors had pressure vessels it's likely  
that would have Amplified the explosions  compared to what happened at Chernobyl   it's almost impossible to guess how bad  the accident at Fukushima could have been   if not for the heroic actions of Masala Yoshida  Iko izawa and all of the other Brave operators   who risk their personal safety at Fukushima  to mitigate the accident the only way to have   prevented this disaster would have been to  move the backup generators to Higher Ground   something that tepco was studying but hadn't  yet committed to do at the time of the accident  
it's almost impossible to improve upon the actions  The Operators took in the minutes hours and days   after the accident so there's nothing The  Operators could have done differently to get   a better outcome what should we learn from the  accident at Fukushima let's talk about nautokan   Khan resigned on September 2nd 2011. in no small  part because of the situation at Fukushima daiichi   not just that it happened but his handling  of it his distracting visit the morning after  
the earthquake his attempted delay of seawater  injection his demoralizing pep talk insulting   the very people Japan was depending on to keep  the crisis from escalating in each case there was   one man that countered Khan Masala Yoshida both  shielded operators from Khan's interference and   rallied them past it when it was unavoidable he  deftly handled Khan's site visit he ignored Khan's   order to pause seawater injection he very tangibly  showed the Fukushima 50 that he would not stand  
for Khan's disrespect and he did all of this in a  culture her seniority and hierarchy are sacrosanct   how a really interesting paper published by  Dr Ruth Ann heising has some insight for us   Dr heising interviewed several employees who were  participating in business process redesign teams   at large companies these teams were working  to make fundamental changes about how their   organizations worked part of the process each  of these teams went through was process mapping  
documenting the steps conversations tools and  other activities required to complete a Core   Business activity like processing an insurance  claim or launching a new product these Maps were   always surprising for the teams that created them  and they often raised existential questions about   employees roles in the organization the  reason was that they revealed the actual   structure of the organization the relationships  the information Pathways that were responsible   for the organization actually being able to get  work done they learned the actual structure of the  
organization was an organic emergent phenomenon  constantly shifting and changing based on the work   to be done and often bearing little resemblance  to the formal hierarchy of the organization   observing the organization is continuously  in the making gave employees an overwhelming   sense of possibility sparking ambition their  experience with the mapping exercise shook   them out of their well that's just the way things  are learned helplessness towards the bureaucracy   and the way that their companies worked we've  all trained ourselves over the course of our  
careers to think that the folks at the top of the  org chart know more than we do and they often do   have helpful holistic perspective about the  company and the industry it operates in but   all of the actual work of an organization all of  its output happens at the bottom of the org chart   and the teams at the edge of the organization  leaders at the top may have a wide perspective   but the edges are where an organization's  detailed knowledge lives and because of  
that the edges are where the majority of an  organization's decisions ought to be made this   is where the organic emergent structure that lets  an organization actually get work done takes shape   which brings us back to yoshida-san ryushu kadoda  the author of one of the books I read researching   this presentation asks several Fukushima workers  how the accident would have been different without   Yoshida and most of them answered with some  variant of we'd have been lost without him   several said something like with Yoshida in the  lead we were prepared to die together if we had to  
when asked why it came down to trust Yoshida  made it clear over his years of leading Fukushima   daichi that he trusted his operators and their  decisions they were able to make decisions and   work in such Harmony during the accident  but because of the trust he placed in them   and Yoshida continually re-earned and  reinforced their trust by doing things   like standing up to the prime minister so what's  the takeaway well depends on who you work for  
if your management resembles naotocon you're  going to have to lean into what the participants   in Dr heising's business process mapping exercise  learned I'm now focused on inventing the board and   not just playing the game trying to see what's  really out there and not arguing too much for   the limitations that maybe aren't so real you  can see this in the way that Yoshida responds   to Khan the rules of the game especially in Japan  are extreme deference to hierarchy and superiors  
but the possibility Yoshida was fighting  for was not blowing up the plant   it's not all Rebellion all the time but it  might mean knocking your deference for your   leaders down a notch or two and trusting yourself  a little bit more so that you can get work done   but if your management is more like masal Yoshida  your job is to lean into the trust that they give   you to try things to use the safety that they  create and the guidance they offer to learn and   to grow and to push the business forward you  likely still have some learned helplessness  
built up from your career and even with high  trust leadership you're still going to have to   learn how to create the game rather than play it  and if you're a leader I hope the lesson here is   obvious I can chart my career by the talks that  I've given because they're always around what   I'm learning in the moment that I write them  my focus right now in leading the engineering   team at Sim is to see what happens when a  company's whole leadership team leans into  
the idea that everything important happens at  the edge of the company and the rest of us are   there to support that to really trust Empower  support and guide not dictate and lead by Road   our engineering team has grown more and taken on  more leadership responsibility than I would have   ever thought possible and we're moving remarkably  fast because of it because of that autonomy   it's been one of the biggest privileges  of my career to be there for it   I hope everyone in this room gets a chance to  experience or maybe even create a team like that  
at some point in your career good things like this  they're worth fighting for thank you [Applause]
End of transcript

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