#1The Fukushima Daiichi Accident A matter of unchallenged basic assumptions Monica Haage, Division of Nuclear Installation Safety, IAEA IAEA International Atomic Energy Agency#2Objectives •Provide a background on the report. • Explain how the work was approached Share the observations and lessons learned IAEA 1#3The Fukushima Daiichi Accident One report by the IAEA Director General • Five technical volumes • The result of extensive international collaborative effort . Five Working Groups 180 experts • 42 Member States "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/IAEA Books/10962/The-Fukushima-Daiichi-Accident IAEA 2#4Human and Organizational Factors and, Safety Culture Analysis Objectives: As a part of the overall IAEA Fukushima Report, examine how human and organizational factors and safety culture contributed to the event in a comprehensive manner to address the "whys" of the event • Perform a systemic analysis of the accident capturing the relationship and synergies with those involved Provide an understanding so that the necessary lessons learned can be acted upon by governments, regulators and nuclear power plant operators. throughout the world IAEA 3#5Basis for a Sound Methodology The human and organizational analysis was conducted in accordance with social and behavioral science procedures, which comprise of four important elements: ◆Recognized methodology. Qualitative data Scientifically-recognized theory Diversified competencies IAEA 4#6Human and Organizational Factors Team • The HOF Team was part of Working Group 2 - 38 experts overall for the Safety Assessment Team The HOF Team -11 experts: •Kathleen Heppell-Masys, Team Lead, CNSC •Monica Haage, Technical Lead, IAEA •Amanda Donges, INPO, U.S. •Hanna Kuivalainen, STUK, Finland •Sonja Haber, IAEA •Cornelia Ryser, ENSI, Switzerland Birgitte Skarbø, IAEA •Per Chaikiat, SSM, Sweden Luigi Macchi, Dedale, France /VTT, Finland •Kunito Susumu, TEPCO, Japan Takafumi Ihara, TEPCO, Japan 47 Broad experience, vast knowledge and various competencies IAEA 5#7Systemic Analysis Data Collection . Ten primary source reports selected for extracting facts. All facts were assigned to a category and one or more attributes • The HOF Team jointly developed a list of categories and attributes • Created a Database of facts assigned a category and attribute (s) Collecting factual information from various other sources: • Collaboration and regular exchange with all the other working groups • 30 additional relevant reports · Reports from IAEA Consultancy Meetings in Japan • Interview with Professor Hatamura, former Chairperson of Investigation Committee on the Accident at the Fukushima Nuclear Power Stations IAEA 6#8Example of Cumulative Database Reading Lis▾ ба Fact Cod T Fact Icf21 14 If4 4 T102 4 T72 4 T74 To the question, "Don't you think it was possible to propose the development of AM based on seismic PSA?" He (Kondo, chairman of the Special Committee on Safety Goals by NSC) answered, "We could have made such a decision. The question was when to make that decision. With regard to seismic PSA, we intended to start it on the occasion of the periodical safety review (PSR). Although the first-round PSR reviewed only internal event PSA, we had no choice about that, I intended to include external event PSA in the second-round PSR 10 years later. (p. 365) "moreover, those additional protective measures were not reviewed and approved by the regulatory authority" (p. 13 and 45) "The legally mandated METI order to continue seawater injection was issued at 10:30 on March 15. This information was shared via teleconferencing at 10:37. The document containing the METI order stated that "reactor injection is to be performed as early as possible, with D/W venting performed as needed.""" (p.219) "The station and head office response HQs were notified that the TEPCO government attaché decision was "the Prime Minister has not approved seawater injection" at 19:25. After deliberation between the head office and station, it was decided that seawater injection would be halted." (p. 183) "However, due to the decision by the Site Superintendent that injection was vital in preventing accident continued in act Category Regulatory culture T Attribute/Qualifier ▾ Description▾ Regulatory practice Timeline (B,D,A▾ B Organization NSC, Government Regulatory Framework Roles & Responsibilities B Regulator Organizational Interfaces. D IF, TEPCO, METI Roles & Responsibilities Roles & Responsibilities Organizational Structure (Hierarchy) 4,900 facts classified into 26 categories, 3 D50 96 attributes 3 D5-94 ron chamber and its ve been injecting seawater into the nuclear run throttle and have begun to temporarily move our contractors and employees not directly involved in this operation to a safe location." [140] As compared with the report made to the regulators, the press release was evidently delayed with severely constrained content. P.43 From their position as an operator under the regulation of the Kantei and other regulators, this action may make sense. But to give this position priority over transparency, while the safety of local residents was at risk, uncovered issues related to their corporate culture. p43 (see page 44 Excerpt from Statements material created by TEPCO) IAEA TEPCO Partion to the public Regulatory Culture Adhered to Procedures or Requirements Corporate Culture TEPCO, other regulators and the Kantei 8#9Analysis: Mapping Exercises Identified and peer-reviewed facts from key sources • Sorted facts by category or attribute for the team to review . . As a team, performed a two-fold mapping exercise identifying relationships, concepts and trends resulting in mini-themes and overarching themes Drafted the text on mini themes and overarching themes based on the mapping exercises Panasonic x Safety Hyth lity Pay same Job TELTRE N Nuclear Definstratore •Risk Awerowess If Relationsh FEAL TEASE •Sapoficiality Tafa Trilay Proust I Jef no T 珍味 TAFIT Risk Management 8158 In Control de DICT 014 sfir 303 Mindset bir Ja 121 314 •Ownership for Safely . Regulatory Body Lack of accanterblyfentersement Lefer What is rok of gulate Changing the game •Who is The mulator? • What motivates regulator? For for Lizan Zalo 益 •Image Control MD 3-1214/ Sef to •Retaliation Jasulatan If tast L H I 2 haters Levsats b wes Safely the Roles +Resumebildes NSC D MSA 23-18 Tue Constants Due to Lepel Zar H Pfir Tefty Constraints 3126 1 11/21 yage Arthanty (Reg Approach) •Lack offramparay 1 Rolety 31623 If 4 T 210 Hands of Insulation μα learning Mindset Comparentated falts Thinking Insuffit sum Luck kital Inconsistent Risk Awareness Risk Met for Safety Indepen "Hard Thinking Non Stragic Regulatory Approach Ayondasun Rationalization Priontization Procrastination Superficiality Changing the cove Roles Respostes Convenient Regulator/ Image Control Lak of transparency 132 Lack of enforcement Constraints fulare to act Regulatory chutney Regulatory Relationships (Complexity.#10Keeping in Mind our Natural Tendencies Learning opportunity Window for opportunity to learn opens up post-accident, some important lessons tends to be immediate Other Important lessons tend to emerge over time and need to be considered Distancing through differencing Our learning after an accident is subject to barriers Mechanism called "distancing through differencing" - "this can't happen here!" • Example: 1999 flooding event at the Le Blayais NPP in France. Oversimplification: Despite the efforts made to analyse the accident from many different perspectives, what happened is describe linearly The hindsight bias It explains the pitfalls of understanding an event. retrospectively The knowledge of the outcome thus deeply influences the understanding IAEA Action Identification Planning Identification Observation Observation Planning Action Action Identification Planning Identification Observation Action Observation Planning Identification Planning Action Action Identification Looking Looking Observation Action back ahead Source: Hollnagel (1998)#11HUMAN AND ORGANIZATIONAL FACTORS 2 Observations and 7 Lessons Learned IAEA 12#12First Observation - Shared Basic Assumptions Over time, the stakeholders of the Japanese nuclear industry developed a shared basic assumption that plants were safe • . Led stakeholders to believe that a nuclear accident would not happen Constrained their ability to anticipate, prevent and mitigate the consequences of the earthquake triggering the Fukushima Daiichi accident Behaviour, artefacts Shared Values, Norms Shared Basic Assumptions IAEA 14#13Shared Basic Assumptions Across Stakeholders Licensee Public/government Regulatory body Behaviour, Artefacts Behaviour, Artefacts Behaviour, Artefacts Shared Values, Norms Shared Values, Norms Shared Values, Norms Shared Basic Assumptions Shared Basic Assumptions Shared Basic Assumptions IAEA "We are safe" 15#14Lessons Learned 1 Licensee Public/govern ment Regulatory body Behaviour, Artefacts Behaviour, Artefacts Behaviour, Artefacts Lessons Learned: 1. Individuals and organizations need to consciously and continuously question their own basic assumptions and their implications on actions that impact nuclear safety. Shared Values, Norms Shared Basic Assumptions IAEA Shared Values, Norms Shared Values, Norms Shared Basic Assumptions Shared Basic Assumptions "Are we safe?" 16#15Reflecting on Basic Assumptions What mechanisms do you have in place to enable you to validate your shared assumptions? • Do you know your blind spots? . What do you take for granted in your area of expertise? What do you pay attention to? What do you not pay attention to? IAEA 18#16The Boundaries of our Basic Assumptions Boundaries of the basic assumptions Unknown unknowns Known knowns Tsunamis are co-related to seismic events Interconnections allow cross feeding of power from one unit to its neighbor Minimum number of staff available onsite at the beginning of an accident is known Formal competences of staff to respond to an anticipated type of accident is known Known unknowns The prediction of tsunami heights Diesels can fail to start and duration of service may be unpredictable Capability to relieve staff if severe condition persists over prolonged period in case of damage to outside infrastructure Psychological and physical condition and ability of staff to respond to an event under severe conditions in a given moment IAEA Surprise. 16#17Lessons Learned 2 and 3 The accident was a surprise outside the boundaries of the basic assumption of the key stakeholders, meaning the stakeholders had not been able to imagine that such an accident could occur. Lessons Learned 2 and 3: Boundaries of the basic assumptions 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. IAEA Unknown unknowns Surprise Known knowns Known unknowns 16#18Second Observation Observation: While the stakeholders involved in the accident at the Fukushima Daiichi NPP were aware of the possibility of isolated issues related to the accident in advance, they were not able to anticipate, prevent or successfully mitigate the outcome of the complex and dynamic combination of these issues within the sociotechnical system. IAEA 19#19Human, Organizational and Technical Factors within the Sociotechnical System Organizational Factors • Vision and objectives Technical Factors • Strategies Integrated Management System Continuous improvements Priorities Knowledge management Communication ΓΙΟΝΑΙ Contracting Work environment Culture • Etc. IAEA ORGANIZAZ FACTORS HUMAN TECHNICAL FACTORS FACTORS • Existing technology • Sciences Design • PSA/DSA I/C Technical Specifications Quality of material Equipment Etc. Human Factors Human capabilities • Human constraints • Perceived work environm't • Motivation • Individuals' understanding Emotions · Etc. 23#20The Systemic Approach to Safety • . • Works to comprehend the whole system of interplay between Humans, Technology and Organization (HTO) As the whole system is far too complex for one individual to comprehend, an integrated approach is needed, which invites different competencies and thinking. Understanding the dynamics of the HTO interactions helps to evaluate the resilience abilities of the sociotechnical system Provides opportunity to take proactive actions to build human and organizational resilience capabilities that support safety outcomes more effectively A systemic approach to safety offers a complementary safety perspective to Defence in Depth IAEA 22 22#21Systemic View of Interactions within the broader Sociotechnical System Legal Bodies Media TECHNICAL TECHNICAL Governmental Ministries TECHNICAL HUM FACTORS Regulatory Body HUMAN FACTOR FAUMAN FACTORS TECHNICAL HUMAN FACTORS Lobby Groups TECHNICU Licensee TECHNICAL HUMAN FACTORS HUMAN FACTOR Work Unions TECHNICAL HUMAN FACTORS TECHNICAL HUMAN FACTORS e Vendors TECHNICAL HUMAN FACTORS Technical Support Organizations TAEA Universities TECHNICAL Professional Associations. TECHNICAL HUMAN FACTOR HUMAN FACTOR Standards Organizations Competing Energy Providers TECHNICU HUMAN FACTOR TECHNICAL HUMAN FACTOR Interest Groups Energy Markets TECHNICA HUMAN N FACTORS TECHNICU HUMAN FACTORS TECHNICAL International Bodies HUMAN FACTORS HUMAN FACTORS Waste Management Organizations#22Lessons Learned 4 and 5 Lessons Learned: Legal Bodies Media 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. IAEA Governmental Ministries Regulatory Body Universities Professional Association: Licensee Standards Organizations Lobby Groups Competing Energy Providers Work Unions Interest Groups Energy Markets International Bodies Vendors Technical Support Organizations Waste Management Organizations 19#23Relation to Safety Culture: Self-reinforcing Dynamics TECHNICAL Strong safety culture HUMAN IAEA FACTORS FACTORS HTO embraces the - systemic interactions 26#24Lessons Learned 6 and 7 6. The regulatory body needs to acknowledge its role within the national nuclear system and the potential for its impact on the nuclear industry's safety culture. 7. Licensees, regulators and governments need to conduct a transparent and informed dialogue with the public on an ongoing basis. IAEA 21#25About the results of the Systemic Analysis A diversity of approaches: Safety Assessment and, • Systemic Analysis Comments from the co-chairs of Working. Group-2 of the Fukushima Report: "HOF Team results based on the Systemic Analysis are aligned with the results from the Safety Assessment and provide further explanations to the current understanding. The methodology used is sound, and it validates the conclusions" IAEA 13#26In Summary • • Systemic Analysis provides a complementary approach to other approaches Safety Culture: regularly challenge basic assumptions The possibility of the unexpected needs to be integrated into nuclear safety approach Prepare for the unexpected 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 nuclear industry's safety culture Transparent and informed dialogue with the public IAEA 28#27Final thoughts "There can be no grounds for complacency about nuclear safety in any country. Some of the factors that contributed to the Fukushima Daiichi accident were not unique to Japan. Continuous questioning and openness to learning from experience are key to safety culture and are essential for everyone involved in nuclear power. Safety must always come first." Yukiya Amano, IAEA Director General IAEA 29#28Thank you for your attention 29