Fukushima Nuclear Accident from a Human and Organizational … · 2018-05-23 · “This report...

Fukushima Nuclear Accident from a Human and Organizational Perspective

Source: http://photo.tepco.co.jp/en/date/2012/201209-e/120911-03e.html

Source: IAEA Fukushima Report, Annex II of Technical Volume 2

Source: National Geographic, March 25, 2011

Source: TEPCO http://photo.tepco.co.jp/en/index-e.html

http://photo.tepco.co.jp/en/date/2011/201105-e/110519-01e.html

Damage to Fukushima Daiichi NPS (1)

Flooded Areas at Fukushima Daiichi NPS ©Tokyo Electric Power Company, Inc. All Rights Reserved.

Source: TEPCO Akira Kawano presentation IAEA Safety Culture Conference 2016

Damage to Fukushima Daiichi NPS (2)

Confirmation result for the main

flooding route by on-site confirmation

surrounding the building

(1) Building entry/exit

(2) Equipment hatch

(3) Emergency D/G air supply louver

(4) Trench, duct (penetration of

cables) etc.

⇒ Flooding of D/G, electric panel

room etc. through these. Unit 1 containment seawater cooling system pump

Unit 1 D/G (1B)

Unit 1 power panel at

turbine building level 1

Unit 5 sea side seawater pump area

Source: TEPCO Akira Kawano presentation IAEA Safety Culture Conference 2016

©Tokyo Electric Power Company, Inc. All Rights Reserved.


Approximately at 3:42 pm (1)

http://photo.tepco.co.jp/library/110519_2/110519_1_1.jpg


Approximately at 3:57 pm


Source: https://commons.wikimedia.org/wiki/File:Fukushima_1_Power_Plant_control_room.jpg

“This report presents an assessment of the causes and consequences of the accident at the Fukushima Daiichi nuclear power plant in Japan, which began on 11 March 2011. Caused by a huge tsunami that followed a massive earthquake, it was the worst accident at a nuclear power plant since the Chernobyl disaster in 1986.”

Yukiya Amano, IAEA Director General

www-pub.iaea.org/books/IAEABooks/10962/The-Fukushima-Daiichi-Accident

2

“whys”

systemic analysis

necessary lessons learned

3

Broad experience, vast knowledge and various competencies 5

Over time

shared basic assumption plants were safe

Behaviour, artefacts

Shared Values, Norms

Shared Basic Assumptions

“We are safe”

Public/GovernmentLicensee Regulatory body

question their own basic assumptions

Public/government

Licensee Regulatory body

“Are we safe?”

Known knownsKnown unknowns

Unknown unknowns

Tsunamis are co-related to seismic events The prediction of tsunami heights

Interconnections allow cross feeding of

power from one unit to its neighbor

Diesels can fail to start and duration

of service may be unpredictable

Minimum number of staff available onsite

at the beginning of an accident is known

Capability to relieve staff if severe

condition persists over prolonged

period in case of damage to outside

infrastructureFormal competences of staff to respond to

an anticipated type of accident is known Psychological and physical

condition and ability of staff to

respond to an event under severe

conditions in a given moment

Surprise

Boundaries of the basic

assumptions

boundaries of the basic assumption

Lessons Learned 2 and 3 :

2. The possibility of the unexpected needs to be integrated into the existing worldwide approach to nuclear safety

3. Nuclear organizations need to critically review their approaches to emergency drills and exercises to ensure that they take due account of harsh complex conditions and unexpected situations.

16Known

knowns

Known

unknowns

Unknown

unknowns

Surprise

Boundaries of the

basic assumptions

aware of the possibility of isolated issues

complex and dynamic combination sociotechnical

19

Organizational Factors• Vision and objectives• Strategies• Integrated Management System• Continuous improvements• Priorities• Knowledge management• Communication• Contracting• Work environment• Culture• Etc.

Technical Factors• Existing technology• Sciences • Design • PSA/DSA• Instrumentation/Controls sys.• Technical Specifications• Quality of material• Equipment• Etc.

Human Factors• Human capabilities• Human constraints • Perceived work environm’t• Motivation • Individuals’ understanding• Emotions• Etc.

too

complementary

22

Systemic View of Interactions within the broader Sociotechnical System

Licensee

Regulatory Body

Universities

Technical Support Organizations

Standards OrganizationsLobby Groups

International Bodies

Media

Professional Associations

Work Unions

Waste Management Organizations

Vendors

Energy Markets

Competing Energy Providers

Interest Groups

Legal Bodies

Governmental Ministries

Licensee

Regulatory Body

Universities

Technical Support Organizations

Standards OrganizationsLobby Groups

International Bodies

Media

Professional Associations

Work Unions

Waste Management Organizations

Vendors

Energy Markets

Competing Energy Providers

Interest Groups

Legal Bodies

Governmental Ministries

Lessons Learned:

4. A systemic approach to safety needs to be taken in event and accident analysis, considering all stakeholders and their interactions over time.

5. To proactively deal with the complexity of nuclear operations, the results of research on complex sociotechnical systems for safety need to be taken into account by all stakeholders involved.

regulatory body acknowledge its role within the national nuclear system and the

nuclear industry’s safety culture

transparent and informed dialogue with the public on an ongoing basis.

• Systemic Approach is complementary to other safety approaches

• Safety Culture: continually challenge basic assumptions

• The possibility of the unexpected needs to be integrated into the safety approach

• Prepare for the unexpected/Prepare to be unprepared

• Take into account harsh complex conditions and unexpected situations into emergency drills and exercises

• Important to consider results of research on complex sociotechnical systems for safety

• Regulatory body needs to acknowledge its role and, impact on the industry’s safety culture

• Transparent and informed dialogue with the public

Lack of a viewpoint of complex disasters

lack of forethought

accident in the form of a complex disaster highlights the inadequacies in crisis management attitude

complex disaster should be sufficiently considered in emergency preparedness.

Source: http://www.cas.go.jp/jp/seisaku/icanps/eng/finalgaiyou.pdf

”When working withcomplexity we need to simplifyto make it manageable.”

RED MATTERS 3-OLOGY

Source: Liv Cardell, founder of Red Matters

Shared

Space

Me

Shared space

External space

Interrelationships:What happens between people, groups and organizations that shapes behaviours

Progression:The enactment based on organizational learnings and evolved understandings

Structure:The management, systems, frameworks, infrastructure created to ensure a systematic approach to safety

Source: Red Matters 3-Ology

RedSTUCTURE PURPOSEStabilize, streamline,control, standardizeBASED UPONFacts, knowledge,calculations, informationCHARACTERISTICSLinear, concrete, operative,short-term, formal, detailsSHAPED BYObjectives, rules, policies, plans, directives, decisionsCOMMUNICATION STYLERhetoric, discussion, debate.Intellectual orientedVALUESTradition, security, power,conformity, predictability

INTERRELATIONSSHIPSPURPOSEAlign, unify, compose, belong, conform,motivate, perform, free willBASED UPONIntuition, emotions, sensitivity, interpretation, normsCHARACTERISTICSCircular, abstracts, informal, dynamiclong-term, inclusive, empathicSHAPED BYValues, norms, assumptions, role-models,impressions, cooperative mind-setCOMMUNICATION STYLEParticipation, presence, dialogue,connection. Heart orientedVALUESCompassion, friendliness, interaction, humanity, recognition

PROGRESSIONPURPOSEDevelop, learn, connect, synthesize, meaning, wise and sustainable decisionsBASED UPONshared experiences, ideas and shared understanding, explorationCHARACTERISTICSOrganic, adaptable, flexible, explorationSHAPED BYThe bigger picture, present state and desired future, evaluation, collaboration mind-set, curiosityCOMMUNICATION STYLEReflection, involvement, dialogue, assessments. Stomach orientedVALUESInterdependence, integrity, variation,creativity, continuous improvements

Source: Red Matters 3-Ology

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Fukushima Nuclear Accident from a Human and Organizational … · 2018-05-23 · “This report...

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