This paper applies a Design Failure Mode and Effects Analysis to the Chernobyl disaster to identify technical, organization and human failures that lead to the 1986 reactor explosion. The RBMK-1000 reactor was built with a dangerous combination of graphite-tipped control rods, a water-cooling system, a positive void coefficient and low enriched uranium. This combination made the perfect environment for meltdown caused by positive SCRAM effect. Procedural violations, inexperienced operating crew, poor communication, and lack of a safety culture compounded with these design flaws created a ticking time bomb. Many of these failure modes were scored to be the maximum severity rating that the DFMEA has, due to the generation environmental damage the health consequences that continue to affect the region. This analysis demonstrates how the absence of risk assessment, mitigation, safety protocols allowed a preventable failure to blow up into a catastrophe that will last generations. Thie findings demonstrate the important role DFMEA has in modern engineering and its importance in preventing future tragedies.

Keywords

DFMEA, FMEA, Nuclear Power Plant, Risk Assessment, Nuclear Meltdown, Chernobyl, Quality