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

2. 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

3. IMPACT AND IMPORTANCE
The second largest nuclear disaster (after Chernobyl) to be given the Level 7 of the INES classification
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)

4. 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

5. 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Outdated technology in reactors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

6. 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

7. 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Outdated technology in reactors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

8. 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

9. 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

10. 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

11. 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

12. REFERENCES
James T. Reason. Managing the risks of organizational accidents
GreenPeace briefing March 2011