Fukushima Nuclear Accident from a Human and Organizational … · 2018-05-23 · “This report...
Transcript of 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
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.
http://photo.tepco.co.jp/en/date/2011/201105-e/110519-02e.html
Approximately at 3:42 pm (1)
Approximately at 3:42 pm (2)
http://photo.tepco.co.jp/en/date/2011/201105-e/110519-02e.html
Approximately at 3:43 pm (1)
http://photo.tepco.co.jp/en/date/2011/201105-e/110519-02e.html
Approximately at 3:43 pm (2)
http://photo.tepco.co.jp/en/date/2011/201105-e/110519-02e.html
Approximately at 3:43 pm (3)
http://photo.tepco.co.jp/en/date/2011/201105-e/110519-02e.html
http://photo.tepco.co.jp/en/date/2011/201105-e/110519-02e.html
Approximately at 3:57 pm
Source: http://photo.tepco.co.jp/en/date/2011/201104-e/110411-04e.html
http://photo.tepco.co.jp/en/date/2011/201103-e/110316-01e.html
Source: http://photo.tepco.co.jp/en/date/2011/201103-e/110324-02e.html
Source: http://photo.tepco.co.jp/en/date/2011/201103-e/110327-01e.html
Source: https://commons.wikimedia.org/wiki/File:Fukushima_1_Power_Plant_control_room.jpg
http://photo.tepco.co.jp/en/date/2011/201103-e/110316-01e.html
Source: http://photo.tepco.co.jp/en/date/2012/201209-e/120911-40e.html
“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