Fukushima Probe Highlights
Nuclear Regulator
Nuclear Power Radiation
EMF Computer Protection
Magnetic Field Detector
By Tsuyoshi Inajima and Stuart Biggs - Dec
27, 2011
When engineering professor Yotaro
Hatamura took the job of heading the independent
investigation into the Fukushima disaster, he said he was
looking for lessons rather than culprits. He may have
changed his mind.
In a 507-page report published
yesterday after a six-month investigation, Hatamura reserves
some of his strongest criticism forJapan’s
atomic power regulator, the Nuclear Industrial and Safety
Agency, known as NISA.
NISA officials left the Dai-Ichi
nuclear plant after the March 11 earthquake and when ordered
to return by the government provided little assistance to Tokyo
Electric Power Co. (9501) staff
struggling to gain control of three melting reactors,
according to the report.“Monitoring the plant’s status was
the most important action at that time, so to evacuate was
very questionable,” the report by Hatamura’s 10-member team
concluded. The committee found “no evidence that the NISA
officials provided necessary assistance or advice.” Even
though NISA’s manual said to stay at the plant, their
manager allowed the officials to evacuate, according to the
report, which doesn’t name the manager.
The preliminary conclusions by
Hatamura, who specializes in studies of industrial accidents
caused by design flaws and human error, includes a slew of
planning failures, breakdown in communication and
operational mistakes by Tokyo Electric and the government
before and after the earthquake and tsunami.
No Power
While the utility supplied the
electricity that kept homes, factories and offices running
in metropolitan Tokyo, the world’s biggest city, lack of
preparation for power
failure in
the Fukushima station left workers reduced to flashlights at
the 864-acre plant site, the size of about 490 soccer
fields.
Batteries in cell phones at the
Fukushima plant started running out on March 11 and with the
failure of mains power couldn’t be recharged, preventing
communication with the on-site emergency headquarters,
according to the report.
Because the utility known as Tepco
hadn’t considered a tsunami overwhelming the Fukushima
plant, no preparation was made for “simultaneous and
multiple losses of power” causing station blackout, the
document says. As a result, the operational manuals lacked
information to help staff restore equipment or power.
The blackout caused the failure of
all personal handyphone system units in the plant, seriously
disrupting communications among workers.
Fractured Communications
Communications became so fractured
that plant manager Masao Yoshida, stationed in the emergency
bunker, didn’t know what some workers were doing. The high
pressure coolant injection system at the No. 3 reactor was
stopped by a worker without authority from plant managers,
according to the report. The reactor was one of the three
that melted down.
In Tokyo,
the central government’s response was muddled by
miscommunication between two teams working on different
floors of the same building, the report said.
The report also criticized the
government for failing to use its system for monitoring the
spread of radiation in calculating evacuation areas. While
the monitoring tool lacked sufficient data for an accurate
assessment because of communication failures, its predictive
functions should have been used, the report said.
Withholding Information
The government also erred in
keeping data on the spread of radiation from the public.
“Information on urgent matters was delayed, press releases
were withheld, and explanations were kept ambiguous,” the
report concluded.
The report by Hatamura, professor
emeritus at University
of Tokyo, serves as a time line for the chaos
that ensued when the record magnitude-9 earthquake knocked
out power and buckled roads before the tsunami flooded
backup generators. Radiation fallout from the reactors
forced the evacuation of about 160,000 people. The
government hasn’t said how many can return and when.
“Tepco, NISA and the government
will brace themselves as the interim report condemned them
all,” Tomoko Murakami, a nuclear researcher at the Institute
of Energy Economics in Tokyo, said today by telephone. “They
will be forced to improve safety measures to reflect what
the report pointed out, such as Tepco’s useless manuals.”
Tepco takes the investigation
report seriously, Osamu Yokokura, a spokesman for the
utility, said by phone today.
“The government committee has done
a thorough investigation, the report didn’t have many
differences from what we have found,” he said.
Hotlines between the central
control room and the reactor buildings worked following the
quake, while workers outside the buildings had a total of
nine transceivers, spokesman Masato Yamaguchi said
yesterday. The company added 29 transceivers on March 13 and
80 more on March 15, Yamaguchi said.
Failed Procedures
On NISA procedures, the report
says the agency’s manual called for inspectors to remain at
Dai-Ichi in an emergency while other officials head to the
offsite emergency command office 5 kilometers (3 miles) away
in Okuma town.
By March 14, all eight NISA
officials, who are unidentified in the report, had left
Dai-Ichi.
“The inspectors were in charge of
gathering live information on the site,” Hiroyuki Fukano,
director-general of NISA, told reporters in Tokyo last
night. “It’s a serious problem that they didn’t do their
job, though it’s a matter of NISA’s system, rather than
individual inspectors,” said Fukano who was appointed after
the former head, Nobuaki Terasaka, was fired in August.
Leaving the Plant
Kazuma Yokota, NISA’s chief
inspector at Dai-Ichi at the time of the quake, said in an
interview with Bloomberg News in April he was one of three
inspectors who left the plant 15 minutes after the temblor
for Okuma. The three reached the center in 15 minutes and
found it wrecked, power down and no working communications,
he said.
A person who answered a call to
Yokota’s cell phone yesterday said it was a wrong number. An
official reached by phone in NISA’s office in Fukushima said
Yokota was not available.
“People are often unaware of the
functions of the organizations they belong to,” Hatamura
told reporters yesterday. “If you don’t understand that
function, you can’t live up to the expectations that people
put on your organization. This is basically what happened at
NISA after the accident.”
Prime Minister’s Questions
Hatamura’s full report is expected
in the summer of 2012, when it will include interviews with
former Prime Minister Naoto
Kan and
other Cabinet officials. Those interviews weren’t completed
for the interim report due to time constraints, according to
a briefing by the Ministry of Economy, Trade and Industry
last week.
The committee interviewed 456
people over a total of 900 hours of hearings by Dec. 16,
according to the report.
Interviewing Kan may be necessary
to reach a conclusion on media reports that former Tepco
President Masataka
Shimizu requested
to evacuate all employees from the plant following the
disaster.
Tepco has denied it made that
request, while Hatamura’s report said the company was
planning a “partial evacuation.”
Hatamura was appointed by the
government in May to lead an “impartial and multifaceted”
investigation into the nuclear accident, the worst since
Chernobyl in 1986.
‘Learning from Failure’
He received his Ph.D. in
industrial mechanical engineering from the University of
Tokyo in 1973 and began studying human error after finding
his students were more interested in how projects can go
wrong, according to the publisher of his book “Learning from
Failure.”
The Failure Knowledge Database
that he set up has studies on more than 1,100 accidents,
including a case study of Tokyo
Electric and
its falsification of nuclear plant maintenance records,
which the utility admitted in 2002. The study concludes the
faked reports resulted from lack of quality control and
proper risk management.
The disaster at Dai-Ichi shows the need for a “paradigm
shift in the basic principles of disaster prevention” at
nuclear power
plants, Hatamura’s committee concluded in the
report. “It’s inexcusable that a nuclear accident couldn’t
be managed because a major event such as the tsunami
exceeded expectations.”
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