Fukushima Report Analysis
Keeping 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)View entire presentation