When Kitty Litter Caused a Nuclear Catastrophe
131 points
5 days ago
| 14 comments
| practical.engineering
| HN
tape_measure
5 days ago
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I'm submitting this based on the current top item "North Dakota law lists fake critical minerals based on coal lawyers' names" [0].

This accident was traced to a manager transcribing "inorganic absorbent" as "an organic absorbent". A more serious example of the need to have competent people with domain knowledge in the room and empowered when documents are written.

[0] https://news.ycombinator.com/item?id=46492161

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daymanstep
19 hours ago
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I'm surprised they made critical material purchasing decisions based on what some guy thinks he heard in a meeting, rather than official written documents written by and cross-checked by multiple engineers.
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12_throw_away
16 hours ago
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> I'm surprised they made critical material purchasing decisions based on what some guy thinks he heard in a meeting

Right? We don't store nuclear waste where I work ... BUT one time we needed to buy a bunch of ethernet cables, basically the same thing. We wrote down our requirements, came up with some options. The engineers evaluated the options before purchasing and checked what we received before installing it. There wasn't even a formal process, it's just ... how you do your job?

Obviously organizational dysfunction is a real thing, particularly at LANL, so I can definitely imagine how this sort of thing can fall through the cracks for various processes. But I feel like but requirements verification should be a rigorously enforced formal procedure before storing nuclear waste in perpetuity.

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jrjeksjd8d
15 hours ago
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The difference is that in a large organization the people documenting the procedure, the people doing the procurement, the people receiving the order and the people packing the drums are all different people. Potentially in different buildings. You can't expect the original scientist who wrote the white paper based on experiments in a glovebox to be present every time they pack waste into drums.
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pixl97
10 hours ago
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Oh and it gets even worse when there are bean counters at the end of the procurement chain.
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GuB-42
17 hours ago
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There is almost never a single cause, here there was 12, it is often called the swiss cheese model. The root cause is a bad transcription, which probably happened many times, but for some reason, this time, all the safeguards failed. It happens sometimes, with catastrophic results. Hopefully, procedures will be adjusted, but in general, you can only minimize risks, not prevent catastrophic events entirely.

It was an expensive mistake, but thankfully, no one died.

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TheGrassyKnoll
13 hours ago
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Reminds me of the Starboard/Larboard nautical terminology. That must have created many disasters over the years. It took the British navy hundreds of years to rectify that one.
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cperciva
19 hours ago
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Not just when documents are written, but also when the practices they describe are implemented.

You don't need to know a lot of chemistry to realize that mixing organics with nitric acid is a bad idea. Why did none of the technicians doing the work say "hold on, this doesn't seem right"?

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bloomingeek
18 hours ago
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My guess, they were afraid to ruffle the feathers of their higher-ups. Yes, that's moronic, but this is the world we can find ourselves in IF the bosses are egotistical kingdom makers.
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navigate8310
16 hours ago
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Or maybe just do as you are told and second guessing the procedure would lead to imposter syndrome
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bombcar
15 hours ago
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Or perhaps "when dealing with nuclear stuff, follow the procedure".
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cperciva
17 hours ago
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Right, people need to feel empowered and not just worried about ruffling feathers.
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PaulHoule
15 hours ago
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The second accident here

https://en.wikipedia.org/wiki/Tokaimura_nuclear_accidents

was an example of where that "empowerment" went wrong. It is usual for workers in Japanese factories to make continuous improvements in process for quality and cost and it is usually a good thing... but criticality accidents involve invisible dangers and "following procedures strictly" in that kind of work saves lives.

Notably Japan has been the world leader in nuclear accidents since the 1980s and some of that is that they kept working on things like fast reactors after many other countries quit and others that are cultural. For instance at American BWR reactors it is routine to test the isolation condenser whenever the reactor is shut down so everybody knew what it sounded like (LOUD!) when it worked but when somebody at Fukushima was asked if it was working they saw a little steam coming out the ports but had never seen it work before and didn't know what to expect.

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coryrc
13 hours ago
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> leader in nuclear accidents since the 1980s

I also want to put things in perspective: far, far more people are dying from fuckups with fossil fuels, but like "Florida man" (Florida has a law that crime reports must be published) we actually report and collect accidents involved in Nuclear production, so you can see every mistake. But you don't see mass protests because natural gas infrastructure failed in Texas and building pipes burst and people froze to death, including a young boy.

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cperciva
14 hours ago
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Let me rephrase that. People need to feel empowered to stop a potentially dangerous process. They definitely shouldn't be empowered to implement new dangerous processes without external review.
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PaulHoule
14 hours ago
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Or modify them. For instance the people at Tokaimura felt empowered to take steps to speed up the mixing, that, plus them mixing a higher enrichment blend led to disaster.
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rob74
17 hours ago
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Thanks for highlighting that, I missed that in the video and was wondering why "anorganic" should be something different than "inorganic" (in my native German it's "anorganisch").

But still, I'm a bit alarmed that a trained nuclear technician would simply follow these instructions and mix organic material with acid without having any second thoughts about it...

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IggleSniggle
16 hours ago
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I think it's worth remembering that this was a storage procedure that was also already abnormal/odd because of the specifics of the existing shielding. I think it's somewhat understandable for a technician to trust that the chemists know what they're doing in that kind of circumstance. If they had concerns, they may have even voiced them, but as is often the case, if the authority confirms that even though it's strange it's correct, it's not surprising that a technician would follow the directive. Even the authority figure may have verbally confirmed, "you said an organic absorbent??" "Yes, that's right, inorganic absorbent." Maybe even in a meeting that was meant to clarify written procedures.
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dredmorbius
13 hours ago
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... transcribing "inorganic absorbent" as "an organic absorbent"...

A literal, or literary, bit-flip.

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formerly_proven
19 hours ago
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Inflammable means flammable? What a country!
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DoctorOetker
3 hours ago
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inflammation of a tissue is when it is rendered inflammable /s
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foobarbecue
17 hours ago
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I did a sort of internship at Los Alamos which involved building some drones. A year or two later I got a call from my advisor there, out of the blue asking me if I had anything immediately available that could do recon underground effectively. I didn't really, so I declined. I asked what they needed it for and he said it would be easier if I got the info from the news. That was kinda terrifying ... turned out to be this incident.

Internship started as this thing: https://youtu.be/hq03MsP1MPI?si=lVpDMLqRN4nfwMiA really great experience.

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PaulHoule
14 hours ago
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I went to school in New Mexico and had really mixed feelings about the culture around Los Alamos and Sandia.

There are a lot of brilliant people there both in terms of science and project management. However, the best person I knew got driven out. But I think also a lot of nepotism and a security clearance culture that filters out really interesting people and leaves behind the dangerously milquetoast.

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foobarbecue
5 hours ago
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Me too, phd at NM Tech. Loved being in Socorro. You?
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hinkley
17 hours ago
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I still find it terrifying that even robots couldn’t survive the Chernobyl hot zone.
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PaulHoule
14 hours ago
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Electronics tend to fail at dosages (20 greys or so) similar to what destroys your nervous system.
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pinkmuffinere
14 hours ago
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I'm a non-bio person. Is that a coincidence, or is that because of similarity between our nervous system and electronics?
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PaulHoule
13 hours ago
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I think it's a good rule of thumb. When they send robots into something like the Fukushima site they don't last long.

My first take is that I'm not surprised from a fermi problem standpoint that you can destroy two computers made from small parts smashed by radiation with a similar dose. But maybe that intuition is wrong because your brain could survive losing a few neurons but a microchip could be 0% functional after losing one transistor. My rule of thumb is about right for conventional chips but you can certainly get rad-hard chips that hold up better:

https://en.wikipedia.org/wiki/Radiation_hardening

Space is a big market for that sort of thing.

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bsder
12 hours ago
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> Is that a coincidence

Mostly it's about penetration.

Any radiation that can get through your skin can do damage. Once that happens, the question is then how much flux is there doing damage.

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cyberax
13 hours ago
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They absolutely could, and only one robot got disabled by radiation. The problem was that robots of that era were nearly useless.

Why they were useless is interesting in itself. It turned out that controlling robots, when all you have is a bad TV camera, is hard. And robots also tend to get stuck on things.

As a result, the "Joker" robot that was helping to clear the roof got its tracks wedged on a firefighters water pipe.

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gambiting
16 hours ago
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They could, if they were specced correctly. Wasn't the story that they intentionally requested robots hardened against lower radiation level than required to not disclose the true extent of the catastrophe? So the German company that built them underspecced the shielding and so they died quickly.
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ceejayoz
14 hours ago
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The real story is a little less dramatic - it got stuck, and that meant it was exposed to the radiation for much longer than planned.
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hinkley
7 hours ago
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That doesn't quite dovetail with the story I've heard about them shooting the elephant's foot with a gun to spall off a sample. I think there's still some damage control in some of the stories.

Which is to say, lies.

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echelon
16 hours ago
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> specced

Totally orthogonal, but you just reminded me of a pet peeve I have.

This word is correct, but I can't stand it.

I wish we spelled this "specked", even though that has a homonym.

Like trafficked, panicked, frolicking, etc.

"specced" makes my brain wince.

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eqvinox
16 hours ago
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> Like trafficked, panicked, frolicking, etc.

Those aren't truncations of longer words though?

I'd write it as spec'ed but that's German grammar with ' as a truncation mark (signifying the omitted "ifi").

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ninalanyon
14 hours ago
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It's also normal English usage.
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HPsquared
12 hours ago
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Maybe spec'd
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themaninthedark
15 hours ago
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More than just a typo:

>In July 2012, LANS issued Solution Package (SP) Report-72, Salt Waste (SP #72) (Revision 1) to address the processing steps for nitrate salt drums. This document concluded that the glovebox procedure must be revised or replaced to ensure that the final waste mixture meets or exceeds 1.2:1 kitty litter/zeolite:nitrate salt as specified by May 8, 2012, LANL-CO white paper.

>In response to SP #72, LANS prepared a major revision to the glovebox operations procedure. Section 10.6 was added to provide instructions for nitrate salt drum processing. Paragraph 10.6[3] stated “ensure an organic absorbent (Kitty Litter/Zeolite® absorbent) is added to the waste material at a minimum of 1.5 absorbent to 1 part waste ratio.” The Board concluded that specifying the use of “organic” absorbent and the omission of the word “clay” in the WCRRF glovebox procedure was not consistent with the direction provided in the white paper.

https://wipp.energy.gov/Special/AIB_WIPP%20Rad_Event%20Repor...

I remember at the time there was also some concern that the swap had taken place due to a green initiative to use renewable sources rather than something that was mined. there were no sources to back that up except the fact that the organic litter is a little over double the cost of clay litter.

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nine_k
18 hours ago
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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.

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ortusdux
17 hours ago
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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.”

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rob74
17 hours ago
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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...
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structural
11 hours ago
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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.

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HeyLaughingBoy
15 hours ago
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Very often the notes contain a lot more information than the ticket. Tickets are often written by people who barely understand the problem.
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touisteur
13 hours ago
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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...
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fsckboy
18 hours ago
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so you're saying this was really an unclear incident?
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nine_k
12 hours ago
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Jokes aside, aren't most incidents a result of lack of clarity, ignored and creatively reinterpreted enough times?
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rmonvfer
16 hours ago
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Love this part

“It’s almost unbelievable that we entrust ourselves - squishy, sometimes hapless bags of water, meat, and bones - to navigate protocols of such profound complexity needed to safely take advantage of radioactive materials.”

Maybe it’s just me but I feel like that all the time, not specifically about radioactive stuff, but about other highly complex and regulated environments where a simple mistake can have catastrophic consequences. As an example, just look at how the aerospace industry operates, there are so many talented scientists and engineers working in every aspect and yet many incidents take place every year due to trivial human errors, from pilots misunderstanding something to technicians not tightening a bolt enough.

Of course it’s not like we can trust anything (anyone?) else other than other humans to do this stuff, but it blows my mind how easily we forget about it.

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bombcar
15 hours ago
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If you map out everything you have to do in a single day, and then work out all the things that you have to avoid for it to not go wrong, it's kind of terrifying.

Robot designers and toddler-minders will know some of these.

We're so used to so many failsafes that the "bare minimum to operate" for many things is frighteningly simple (very early electric wiring, for example).

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mikestorrent
14 hours ago
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> there are so many ... and yet many incidents take place every year

If there weren't so many of us, it would be a lot harder to accept the losses.

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elzbardico
19 hours ago
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"Wrong Kitty Litter Caused a Nuclear Catastrophe"

As an owner of a particularly opinionated Orange Cat, I can relate.

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square_usual
18 hours ago
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Why is it always the oranges? My orange is also very picky!
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hinkley
16 hours ago
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Orange boys are outspoken, sometimes to their own detriment.

Orange is overrepresented in house cats and underrepresented in feral cats. The interpretation of this is that what selects for a kitten at a shelter is an evolutionary disadvantage when in the wild.

I have owned a yellow girl (dilute orange) who was too clever by half, an orange boy who was very sweet but dumb as a post, and an orange boy with 3 brain cells most days, except he loans them out occasionally and without notice.

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mystraline
17 hours ago
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Its the "1 shared braincell between all orange cats" is the problem :D
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cozzyd
19 hours ago
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I had my thesis experiment stranded at WAIS due to this incident. The good thing is I didn't have to go to WAIS ever again...
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csours
16 hours ago
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https://en.wikipedia.org/wiki/Tacit_knowledge

Well, I knew what I meant.

I tried to commit documentation to our source repository; I was told to upload it to the documentation site instead.

The documentation site that we've used for one year, subsequent to the previous documentation site the we used for 3 years, subsequent to the previous documentation site that we used for 5 years.

Following the trend, by the end of this year we will migrate documentation every 5 minutes, degrading every time.

At least source code can be migrated with fidelity. (The main branch anyway)

Who me? Bitter and scarred not at all!

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PaulHoule
14 hours ago
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I have a strong preference for checking in docs with the source code but I'm a software dev.

We have a data team where I work that has a huge Confluence Wiki that helps them maintained shared reality about procedures and standards. I never log into it, if I need to know something from their point of view I go next door and ask one of them.

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thomasjudge
19 hours ago
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Today I learned of the existence of "organic, wheat-based cat litter"
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pfdietz
18 hours ago
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Organic cat litters have the advantage the results can be composted.

They have the disadvantage that they don't control odor well, and when composted smell even worse. So don't try to compost them at home.

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AnimalMuppet
17 hours ago
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Try Smart Cat. It's grass-based, not wheat-based. It controls odor far better than clay-based cat litter.

Only problem I've had with it was when my dog decided that it smelled good enough to eat. Of course, it pulled all the moisture out of the dog's mouth and left it with a stuck-on clump that it couldn't get rid of.

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nick49488171
19 hours ago
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Sounds like grape nuts
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SunshineTheCat
18 hours ago
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That is the most horrible and accurate comment I've read so far today lol
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hinkley
16 hours ago
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I tried my dad’s grape nuts once and I never felt the gulf between us wide as I did in that moment. WTF, man.
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macintux
16 hours ago
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Lots, and lots, of sugar helps.
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MBCook
14 hours ago
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I was surprised when I walked into a pet store last week to see an aisle cap advertising a new tofu based cat litter.
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elzbardico
17 hours ago
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Not sure if available in the American market, but I had good experiences with Cassava root based ones, though it is expensive.
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syntaxing
17 hours ago
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Kinda cool how the safety system seemed to work
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cratermoon
10 hours ago
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This may be hijacking the thread, but I had an interesting experience lately. Bear with me, Los Alamos National Laboratory is part of the story.

I'm a film photographer, and I had been taking my color film to a lab to be processed and scanned. A couple of months ago the lab let me know that the turnaround time for scanning would be a couple of weeks instead of a few days. Some two months later, I still had not gotten my film back. I went to the lab and spoke with the owner, and he said that LANL was sending him so much film to develop and scan that he couldn't get to his other customers, and he expected that the volume would increase. He was nice enough to give me my undeveloped film and and refund the prepaid bill.

I did not ask, as I didn't want to piss of the owner, but I have many questions. Why is LANL sending so much film to a lab for developing? Why can't LANL set up their own film developing and scanning lab, it's not nuclear engineering, it just requires some equipment and a little expertise. Why now? Why are the even using film these days? Why did the lab's owner feel it necessary to prioritize LANL's business over others, rather than putting it in the queue to wait its turn?

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pixl97
10 hours ago
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>Why can't LANL set up their own film developing and scanning lab

Are you asking why a government agency can't just magic up random money and employees during a time the parent government is saying privatization and getting rid of government employees is the way to go?

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cratermoon
9 hours ago
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No. Perhaps I should have noted that LANL was established in 1943. They obviously used film, and more obviously would not have sent it to some random lab for processing. Did they lose that capability?

Also, LANL is an exception to general gutting of federal agencies. It's been given a record budget this FY. https://sourcenm.com/briefs/lanl-expecting-boon-from-congres... That budget was set in the Biden administration. The current administration wants to resume nuclear weapons testing. https://www.npr.org/2025/10/30/nx-s1-5590818/trump-nuclear-t...

Speaking of privatization, LANL is privately managed and operated by Triad National Security, LLC.

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mystraline
17 hours ago
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I keep asking this question:

"Hot" nuclear waste means theres still a lot of energy left to capture. Why are we disposing of materials that still have a lot of energy to capture? Seems like the closer we get to lead, in terms of capture, the better.

It would be like taking my half-full of gas car to the pump, dumping the existing gas, and getting fresh. Its a waste of energy, waste of resources, and generates worse nuclear waste.

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philipkglass
16 hours ago
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The materials are still full of potential energy, but it's much more expensive to reprocess them than to mine fresh uranium. It's even more expensive to reprocess them without incidentally releasing more radioactive contamination into the environment. (Several countries reprocess nuclear fuel now or did so in the past, but the facilities have always released more radioactive material into the environment than simple storage.)

It's kind of like why old and broken polyvinyl chloride pipes go to landfills instead of being burned as fuel in power plants. Even though PVC is flammable, the cost of burning PVC and capturing its carcinogenic combustion byproducts is a lot greater than burying waste PVC and burning fossil hydrocarbons.

In the far future, uranium mining costs might rise enough that it makes economic sense to reprocess old spent nuclear fuel. In the early days of the atomic age people thought that reprocessing and breeder reactors would be necessary because uranium was believed to be very rare on Earth. Vigorous exploration programs and new mining techniques proved this belief to be false by the end of the 1960s, and the situation hasn't changed since then. It's safer and cheaper to mine fresh fuel and just store the old fuel without any sort of reprocessing.

See e.g.

Bunn, Matthew G., Steve Fetter, John P. Holdren, and Bob van der Zwaan. 2003. The Economics of Reprocessing vs. Direct Disposal of Spent Nuclear Fuel (PDF):

https://dash.harvard.edu/server/api/core/bitstreams/7312037d...

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tonyarkles
16 hours ago
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There’s a lot of nuance to the answer and I’m not a nuclear engineer, just an EE and occasional nuclear enthusiast. The biggest issue is the cost-effectiveness of reprocessing the “waste”, which you are completely correct about still having a ton of residual energy available, back into a useable fuel for a sustained nuclear chain reaction.

Some of the fission products that are produced in reactors are actively harmful for sustaining a chain reaction (neutron poisons), Xenon-135 being a prime example. Xenon-135 only has a half-life of about 9 hours (which means it’s pretty spicy) but it also has a massive neutron capture cross-section. If it doesn’t capture a neutron, it emits a beta particle (electron/positron), which doesn’t contribute to sustaining the reaction; if it does capture a neutron it becomes Xenon-136 which is pretty stable. In both cases, it’s sitting in the fuel but either useless (yay) or actively hurting the neutron economy (boo).

At some point in the future it might be economically advantageous to reprocess “used once” nuclear waste and use it in a second cycle but for now it’s way cheaper to get more fresh uranium and process that into fuel instead.

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dkbrk
7 hours ago
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That's not what "hot" means in this context. "Hot" means "highly radioactive", i.e. high number of decay events per second, high concentration of short half-life isotopes, high power/volume resulting from radioactive decay.

Nuclear reactors do not work off radioactive decay. U-235, for example has a half life of 704 million years. Radioisotope thermal electric generators [0] by contrast do run off radioactive decay, an isotopes used for that application have short half-lives, such as Pu-238 with 87.7 years.

Commercial nuclear reactors use unenriched or minimally enriched fuel. This means that, within a fairly short period of time, the percentage of fissile material in the fuel drops to the point where continuing to use it is no longer economical. At that point the fuel is a mixture of extremely hot fission products, transuranics, unreacted fuel, and non-fissile (but fertile) isotopes such as U-238.

It's not practical to use the decay energy from the fission products for power. What would make much more sense would be to remove the fission products and recycle the fuel that remains into new fuel (for a reactor that's designed to use it). This would be a much more efficient use of mined nuclear fuel (allowing nuclear power to be used for thousands of years), it would vastly reduce the volume of nuclear waste, and it would mean nuclear waste would only be hazardous for decades to centuries.

The US was on the path to this with the Integral Fast Reactor and Pyroprocessing [1] developed by the Argonne National Laboratory. This was killed [2] in 1994 by the Clinton administration. Not for any technical reason, but because it was a "threat to nuclear non-proliferation". How that makes sense when, to the best of my knowledge the process developed by Argonne couldn't be used to produce weapons-grade material, and even if it could the US already had nuclear weapons so it wouldn't be proliferating it to a non-nuclear country, I don't know. But, apparently, since some other forms of nuclear waste reprocessing can be used to generate weapons-grade material (by extracting Pu-239), it was a bad symbol so it had to go.

[0]: https://en.wikipedia.org/wiki/Radioisotope_thermoelectric_ge...

[1]: https://en.wikipedia.org/w/index.php?title=Integral_fast_rea...

[2]: https://en.wikipedia.org/w/index.php?title=Integral_fast_rea...

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cyberax
13 hours ago
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They just don't produce that much power. We're talking about hundreds of watts per barrel. You can get more energy by putting a water barrel on your roof.

And in this case, the reaction had nothing to do with nuclear energy. It was a regular chemical reaction, that got into thermal runaway.

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avalys
17 hours ago
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Not really a catastrophe, more like “problem”.
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1970-01-01
17 hours ago
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People were harmed. In terms of wasted dollars, it qualifies as a catastrophe
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terminalbraid
17 hours ago
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Did you read the article at all? No, it was an actual catastrophe. There was damage, years of disruption for the work going on down there, a close call for the people working down there, years of cleanup running half a billion dollars.
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cozzyd
12 hours ago
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Yes, but "problem" doesn't have "cat" in it
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jokoon
17 hours ago
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this really needs a TLDR

after reading a summary, this title is very click-baity

The title reads like "a cat got into a nuclear plant, got contaminated in a and spread radioactivity with cat litter stuck to its paws"

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