FUKUSHIMA DAI-ICHI NUCLEAR DISASTER Organizational accident analysis Borriello Salvatore Del Vecchio Roberta Di Salvatore Filippo

FUKUSHIMA NUCLEAR POWER PLANT 3.5-square-kilometre site in the towns of Ōkuma and Futaba One of the 15 largest nuclear power stations in the world It produces 30% of Japan energy requirements Managed by TEPCO, the biggest Japanese electric company

IMPACT AND IMPORTANCE The second largest nuclear disaster (after Chernobyl) to be given the Level 7 of the INES classification 300.000 people evacuated the area Released radiation equal to 1/10 of Chernobyl Polluted more than 1/4 of the world's oceans International Nuclear Events Scale (INES)

SWISS CHEESE MODEL 1. PLANT DESIGN: 2. EMERGENCY TOOLS: EARTHQUAKE & TSUNAMI 1. PLANT DESIGN: Tsunami risk understimated Lack of supplying power and cooling water injection systems 2. EMERGENCY TOOLS: 3. WORKERS TRAINING: Deficiency of practical training Undefined relationship system with the Regulator, Siting community and the Public 4. INFORMATION SHARING: DIFESE HARD E SOFT Aspetti concorrenti gerarchici, procedurali e situazionali 5. CHAIN OF COMMAND: Confusion in response actions due to orders from headquarters and the Prime Minister’s Office DISASTER

SAFETY INFORMATION SYSTEM ACTIVE FAILURE Earthquake & Tsunami No direct contact between Government and TEPCO No timely application of security protocols No communication of fallout risks to population Ambiguous chain of command LOCAL WORKPLACE FACTORS Weak points in site design Outdated technology in reactors Lack of maintenance Gaps in education system Logistic weakness in security protocol ORGANIZATIONAL FACTORS

LOCAL WORKPLACE FACTORS No direct contact between Government and TEPCO Information from TEPCO are filtered by the Nuclear Energy Agency before arriving to Prime Minister’s Office No timely application of security protocols TEPCO delays on using sea water to cool the reactors because it would have eroded and made the reactors out of order No communication of fallout risks to population People are informed about the real gravity of the disaster only by foreign media Ambiguous chain of command Workers do not know if follow dispositions from TEPCO or from Prime Minister’s Office

ORGANIZATIONAL FACTORS Weak point in Site design Seawalls are able to face waves up to 6 meters and the diesel power generators are underground and risk flooding Outdated technology in reactors Reactors with presence of zirconium in their core are used Lack of maintenance Vent valves and other reactors’ parts have not been checked by several years Gaps in education system The emergency task force does not know where the vent valves are Logistic weakness in security protocol Portable emergency generators are not located on-site

BANKRUPTCY-CATASTROPHE CHART Study of the geological risk and Tsunami Decision not to raise the seawalls Improvement of emergency procedures No investment on emergency power tools Building reactors n° 5 and 6 PROTECTION Seawalls and underground construction Identified cracks in the cooling system Several accidents with loss of radioactivity CATASTROPHE Not latest generation reactors PRODUCTION * Lack of investment in safety is equivalent to increases in production because it reduces costs

RECOMMENDATIONS SOFT (combination of paper and people): Emergency training should be regularly performed Wide-ranging risks for natural disasters should be analyzed in order to adopt measures Mechanism for information sharing should be developed Division of roles with central and local government should be clarified Functions and requirements should be clarified for each position during emergencies

RECOMMENDATIONS HARD (technical devices): Various tools of supplying power should be reinforced Low pressure injection of cooling water should be implemented The latest technology should always be used

CONCLUSIONS It is not enough to give orders from the top, it is necessary to make people internalize them Safety is essential, all indispensable costs have to be supported Never underestimate the little causes: the “butterfly effect” is a typical feature of complex systems In design also low probability natural events have to be considered

REFERENCES James T. Reason. Managing the risks of organizational accidents www.tepco.co.jp www.wired.com www.nationalgeographic.com www.wikipedia.com www.greenstyle.com GreenPeace briefing March 2011 www.blastingnews.com www.noaa.org www.ilfattoquotidiano.it