Gist of panel’s report on Fukushima accident

The following is the gist of an interim report of a government panel investigating the Fukushima nuclear accident released on Dec. 26.

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* Problems with response by various government agencies after outbreak of accident

– Improper functioning of off-site center serving as local base for nuclear accident response

Although the center was established about 5 kilometers from the Fukushima No. 1 nuclear power plant, no forethought was given to the possibility of a simultaneous nuclear accident and natural disaster. Therefore, the center’s structure did not take into consideration the possibility of an increase in radiation levels.

– Response of Prime Minister’s Official Residence

Communication was insufficient between the fifth floor office where the relevant Cabinet ministers, the chairman of the Nuclear Safety Commission and executives of Tokyo Electric Power Co. had gathered to make decisions in response to the accident and the team of high-ranking ministry officials who had gathered at the basement.

* Problems with response to accident at the Fukushima No. 1 nuclear power plant

– Erroneous reading of operation of isolated condensers at the No. 1 reactor

Workers erroneously thought the isolated condenser (IC) was operating normally. It is unlikely that those working at the plant as well as those at TEPCO headquarters thoroughly understood the functioning of the IC. This was extremely inappropriate and was likely a major factor that led to a delay in cooling the reactor core.

– Mishandling of alternative pumping in of water to No. 3 reactor

Workers manually stopped the high pressure coolant injection because of concerns equipment was damaged and radioactive materials were leaking. However, without securing an adequate alternative means of pumping in water, the workers understated the risks involved and failed to reduce the pressure to allow for alternative pumping in of water.

* Problems with measures to prevent spread of damage

– Problems with utilization of the System for Prediction of Environmental Emergency Dose Information (SPEEDI)

If the SPEEDI calculation results had been used, the various local governments and residents would have been able to select more appropriate evacuation routes and methods. Evacuation instructions issued by the central government did not reach all the concerned local governments in the targeted evacuation zone in an expedient manner, and the contents of those instructions also lacked specifics.

– Problems related to providing information to the public and international community

The central government repeatedly said “there will be no immediate effect on human health” in providing information related in particular to the melting of the reactor cores, the dangerous situation at the No. 3 reactor and the effects of radiation on human health. That explanation was difficult to understand.

The delay in releasing information that should have been disclosed immediately and the tendency to make vague explanations were not appropriate in terms of communicating the risks involved.

Releasing contaminated water into the ocean without prior explanation to neighboring nations led to distrust of Japan’s response to the nuclear accident among those nations.

* Inappropriate measures beforehand to deal with tsunami and severe accident

– Problems with forecasts about tsunami

Revisions of inspection guidelines for anti-quake design took five years and were completed in September 2009. However, the process was not used as an opportunity to come up with new measures to deal with tsunami.

No confirmed efforts were made by the regulatory agency to present methods to appraise tsunami or set appraisal standards for the effectiveness of anti-tsunami measures.

In 2008, when the risk of tsunami was again considered, an expected tsunami exceeding 15 meters was given for the Fukushima No. 1 nuclear power plant. But TEPCO officials judged that the figure was nothing more than a hypothetical one.

From a study released that year, TEPCO also obtained wave heights exceeding 9 meters through calculations using a source model of the Jogan tsunami of 869. But TEPCO officials did not view such studies as being based on sufficient grounds, including the uncertainty of the tsunami source model. No efforts started for specific measures.

– Response to severe accident exceeding design standards

There was insufficient recognition of the risk of tsunami. Although consideration began in 1992, it did not lead to regulations. Electric power companies could decide what measures to take.

* Functioning of nuclear safety regulatory agency

(1) Secure independence and transparency. There will be a need to have the agency assume the responsibility to explain its actions along with giving it the proper authority, funding and personnel.

(2) There will be a need for specialized ability to allow for providing advice and guidance based on expert knowledge during emergency situations as well as management ability to allow for efficient functioning of the organization.

(3) There will be a need for persistent scrutiny of developments within academic organizations, specialized journals and overseas regulatory agencies as well as to continuously obtain the knowledge needed for regulatory purposes.

* Preliminary conclusions

(1) TEPCO did not implement measures based on an assumption of a severe accident caused by tsunami as was the case with this accident. The same thing can be said about the regulatory agencies.

(2) For events in which an extremely large scale of damage is forecast, even if the evaluation is made that the probability of such events is low, there is a need to recognize the risk and implement necessary measures.

(3) Measures to deal with multiple disasters considered unlikely will be an important point in the future review of the safety of nuclear power plants.

(4) There is no denying the weakness in a perspective that took into consideration a much larger picture. The excuse that responses could not be made because of the special nature of the situation, in which a tsunami went beyond expectations, will be unacceptable.

From the above points, there will be a need for a conversion of the framework for the fundamental thinking related to anti-disaster measures for gigantic systems that could lead to serious damage.

Asahi Shimbun, December 27, 2011
http://ajw.asahi.com/article/0311disaster/fukushima/AJ201112270050

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 Panel: Wide communication gaps hampered response in Fukushima

Soon after the March 11 earthquake struck, then Prime Minister Naoto Kan and other senior officials gathered in his fifth floor office and effectively became the central decision-making body for the nuclear accident unfolding in Fukushima Prefecture.

But largely unaware of this formation was a task force in the basement of the same building that was set up under a special measures law to deal with nuclear accidents.

Communication was lacking between the two groups—both of whom initially thought they were in charge of dealing with the crisis at the Fukushima No. 1 nuclear power plant.

And that was just one of the many major problems in handling information that caused the slow response to the nuclear disaster, according to an interim report issued Dec. 26 by a government panel.

The panel cited not only the warped organizational structure, but also a lackadaisical attitude toward collecting information and an insistence on controlling the flow of data by those in the Prime Minister’s Official Residence.

Those problems exacerbated the confusion and affected decisions on cooling the damaged reactors, securing the safety of Tokyo Electric Power Co. workers at the plant, and issuing evacuation orders for residents living near the site, the panel said.

The task force was established at the crisis management center in the basement of the Prime Minister’s Official Residence soon after the quake and tsunami struck. The team consisted of high-ranking officials of various government ministries who were coordinating a swift gathering of information to allow for appropriate decisions to be made.

But Kan’s group, including Nobuaki Terasaka, then director-general of the Nuclear and Industrial Safety Agency (NISA), and Haruki Madarame, chairman of the Nuclear Safety Commission, gathered on the fifth floor to discuss how to respond to the accident as well as deciding on the evacuation zones.

There was no legal basis for the formation of Kan’s group, the panel said, but it appointed itself the leader in decisions regarding the nuclear accident.

“At a time when the central government had to deal with the accident by bringing together all of its capabilities, communications between the fifth floor and the basement were insufficient,” the interim report said.

Data that never bridged that communications gap included the results of a forecast made by the System for Prediction of Environmental Emergency Dose Information (SPEEDI), which is designed for use in deciding if evacuation orders should be issued in the event of a nuclear accident.

On March 11, officials of the science ministry, which has jurisdiction over SPEEDI, calculated the expected spread of radioactive materials on the assumption that such substances had spewed from the Fukushima No. 1 plant at a rate of 1 becquerel per hour.

The results were passed on to NISA, which handles information dispersal during nuclear accidents. NISA officials, in turn, sent the forecast to the Prime Minister’s Official Residence.

Attached to the forecast was a supplementary document noting that the results were of low reliability since they were based on a hypothetical source of radioactive materials.

A Cabinet Secretariat official in the basement who received the information decided it was only reference material and did not report it to the fifth floor.

The panel’s interim report said a different course in discussions could have taken place if the SPEEDI forecast had been passed on to those on the fifth floor.

GOVERNMENT, TEPCO NOT IN SYNC

The report also pointed to an insufficient meeting of the minds between central government officials and TEPCO officials, including over the issue of whether seawater should be used to cool the reactors.

On March 12, Kan asked Madarame about the possibility of the reactor core reaching a critical state if seawater was pumped in. Madarame responded that there was little need to consider that possibility, but Kan was not convinced.

Ichiro Takekuro, a senior TEPCO official, called Masao Yoshida, head of the Fukushima No. 1 nuclear plant, and strongly asked that he hold off on pumping in seawater. In fact, seawater was already being pumped in at that time.

Because of that development, a decision was made to call the measure an “experimental pumping” of seawater.

Meanwhile, Yoshida decided to continue with the pumping because his primary concern was cooling the reactors.

While a teleconferencing system had been set up, the mikes could not pick up Yoshida’s quiet orders to his subordinates to continue pumping in seawater—even if he gave instructions to do otherwise.

Soon thereafter, Yoshida said in a voice everyone could hear to suspend the pumping. No one in the Prime Minister’s Official Residence was told what was actually going on at the Fukushima plant.

The lack of communications was also evident on whether TEPCO was pulling out of the stricken plant.

On March 14, TEPCO officials became concerned about the dangers to the many workers at the plant due to damage to the containment vessel of the No. 2 reactor.

Then TEPCO President Masataka Shimizu called Terasaka, the NISA director-general, and said, “We feel there is the possibility of removing our workers if the situation becomes more serious.”

Shimizu did not mention that key personnel in charge of the reactor would remain at the plant because their presence was considered an accepted precondition.

However, those in the Prime Minister’s Official Residence took Shimizu’s comment to mean that all TEPCO workers would abandon the plant.

Kan summoned Shimizu and asked him if TEPCO was giving up on controlling the reactors. Shimizu responded that that was not the case.

ATTEMPTS TO CONTROL INFORMATION

The interim report shows that the central government tried to control the flow of information to the public.

On the morning of March 12, Koichiro Nakamura, NISA deputy director-general for nuclear safety, said at a news conference, “Some of the nuclear fuel has been exposed and it is possible that part of the cladding has begun to melt.”

At a 2 p.m. news conference, Nakamura went further, saying, “It is likely that melting of the core has begun.” He made the comment after receiving prior approval from Terasaka.

But Terasaka later learned of a request to first inform the Prime Minister’s Official Residence before making any announcement. Terasaka issued a warning to Nakamura, and the NISA deputy director-general for nuclear safety stopped giving news conferences.

NISA initially held news conferences at intervals of one to two hours. But the gap between the news conferences gradually widened, and NISA officials stopped referring to melting at the reactor core in subsequent formal news conferences.

On March 12, the head of TEPCO’s Fukushima local office released a photo of the No. 1 reactor after its housing building was damaged by an explosion.

Officials at the Prime Minister’s Official Residence cautioned Shimizu about releasing such information without contacting the office beforehand. Thereafter, TEPCO officials sought the approval of the Prime Minister’s Official Residence before releasing any information, leading to delays in public disclosure of important data, the panel’s report said.

On March 14, the pressure in the containment vessel for the No. 3 reactor increased to dangerous levels. Officials at the Fukushima plant informed TEPCO officials of the situation before 8 a.m.

The TEPCO officials then contacted NISA officials on the fifth floor office of the Prime Minister’s Official Residence, seeking approval to disclose the information.

However, not only were TEPCO officials kept waiting, but they were also told not to release that information because approval had not been given.

At 9:15 a.m., NISA announced the conditions at the plant. Less than two hours later, at around 11 a.m., an explosion occurred at the No. 3 reactor.

The interim report also criticized comments made at news conferences by Cabinet ministers, including then Chief Cabinet Secretary Yukio Edano.

Edano repeatedly said about radiation from the Fukushima accident: “There will be no immediate effect on human health.”

The report said such wording was difficult to understand.

“It is unclear if it means there is no need to worry about effects on human health or, conversely, if there may be effects on human health over the long term,” the report said.

At a Dec. 26 news conference, Edano said, “I said from the time I was chief Cabinet secretary that transmission of information to the public was not sufficient, so I believe that is something we have to reflect on and learn from.”

NISA’S PASSIVE STANCE

NISA’s passive stance in gathering information also came under fire in the interim report.

A teleconferencing system allowed those at TEPCO headquarters, the Fukushima No. 1 nuclear plant and an off-site center in Fukushima to share information almost simultaneously about what was happening within the plant. But NISA officials never learned about that system and were slow in sharing information.

NISA did not send any official to TEPCO. The agency also made no effort to bring in a TV monitor for teleconferencing purposes, the report said.

“There was a lack of awareness and sense of purpose of fulfilling the role of being an aggressive and active hub for information by taking flexible measures,” the interim report said.

NISA inspectors at the Fukushima plant also appeared to have deserted their posts at a crucial time.

On March 12, the five inspectors at the plant obtained approval from NISA’s head office to move to the off-site center 5 kilometers from the plant because radiation levels had increased.

That move was made during a critical time at the plant. Alternative methods of pumping in water and venting were desperately needed because the pressure vessel was believed to have been damaged due to an increase in pressure within the containment vessel of the No. 1 reactor.

“Doubts remain as to whether the decision to leave the site at a particularly crucial time was the appropriate thing to do,” the report stated.

The inspectors received documents from TEPCO workers and passed on that information by phone to NISA.

No effort was made to directly oversee the pumping of water into the reactors nor was any attempt made to play a leading role in taking part in discussions on responding to the nuclear accident.

“There was a lack of awareness of being in a position on the front lines for the central government in dealing with the accident,” the report stated.

Jin Nishikawa and Naoya Kon, Asahi Shimbun, December 27, 2011
http://ajw.asahi.com/article/0311disaster/fukushima/AJ201112270046

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 Fukushima accident shows need to prepare for the unexpected: panel

TOKYO, Dec. 26, Kyodo—A government panel investigating the nuclear crisis at the Fukushima Daiichi power plant said Monday the accident shows the need to prepare for unexpected events if the consequences of them happening could be disastrous, referring to the poor emergency responses of the plant’s operator and the government.

Releasing an interim report following around six months of investigation, the panel said that many problems related to the crisis were linked to the absence of measures to deal with severe nuclear accidents caused by tsunami as well as the failure to assume that a nuclear crisis could occur in combination with a natural disaster.

“It cannot be denied that people who have been involved in nuclear disaster response and those in charge of managing and operating nuclear power plants have lacked the whole-picture viewpoint in nuclear disaster preparedness,” the report said.

“The nuclear disaster prevention program had serious shortfalls,” and the fact that tsunami exceeding assumptions caused an extraordinary situation cannot be an excuse for inadequate management of a nuclear accident, it said.

The remarks contrast with the outcome of an in-house investigation conducted by plant operator Tokyo Electric Power Co., which blamed the larger-than-expected tsunami for the failure to prevent the world’s worst nuclear accident since the 1986 Chernobyl disaster.

With key buildings flooded by tsunami waves more than 10 meters high, the plant located on the Pacific coast in northeastern Japan lost nearly all of its power sources and consequently the ability to cool the reactors and spent fuel pools.

The report by the investigative committee led by Yotaro Hatamura, a professor emeritus at the University of Tokyo, said TEPCO misjudged and poorly handled the situation at the Nos. 1 and 3 reactors, which eventually suffered meltdowns along with the No. 2 reactor.

As for the No. 1 unit, injecting water into the reactor by using fire trucks was delayed mainly because officials at the plant’s emergency headquarters mistakenly thought that a cooling system called an isolation condenser was functioning when it was not.

There was “a good chance” the actual situation could have been noticed, the report said, but reactor operators and headquarters staff apparently did not possess sufficient knowledge about the equipment itself or how to handle it, which was a “quite inappropriate” situation for a plant operator.

TEPCO “had not expected a situation in which all power sources would be lost at multiple reactors simultaneously due to an extremely severe natural disaster, and it had not provided enough training and education to respond to this situation,” the report said.

In the case of the No. 3 reactor, meanwhile, operators on duty switched off an emergency cooling system called a high pressure coolant injection without securing alternative water injection methods, and did not seek instructions from their managers.

If workers had been able to release the pressure in the Nos. 1 and 3 reactors and start injecting water earlier, the reactor cores might not have been damaged as much as currently believed and the amount of radioactive substances released might have been smaller, the report said.

The government’s response during the early stage of the crisis was also problematic, with communications among officials at the prime minister’s office insufficient and the emergency response center in the industry ministry not functioning well in performing its role of gathering information as stipulated in the nuclear disaster response manual.

Members of the industry ministry and the nuclear safety agency were “strongly frustrated by the lack of speed in information provision” by TEPCO, but even so they did not take action such as sending agency staff to the company’s head office, the report said.

The committee also said the government’s evacuation order issued to residents around the plant was not specific so that it was tantamount to telling them to “just run.” In some cases, residents were found to have taken an evacuation route where radioactive substances had spread.

Summarizing its findings, the report said that TEPCO did not take steps to handle severe accidents caused by massive tsunami and nuclear authorities acted similarly. The possibility of such an incident was seen as very low and treated as unlikely.

“But even if it is a phenomenon with a very low probability of occurring, it does not mean that you can ignore it. If an irreversible situation is going to happen...measures should be taken to prevent the situation,” the report said.

Since launching its investigation in June, the investigative committee had conducted hearings with a total of 456 people as of Dec. 16. It also plans to question Naoto Kan, the prime minister when the crisis erupted, and will release its final report next summer.

Gist of investigation report on Fukushima nuclear accident

The following is the gist of the interim report issued Monday by a government panel investigating the nuclear accident at Tokyo Electric Power Co.’s Fukushima Daiichi power plant.

The government:

— failed to communicate well within the prime minister’s office.

— had problems gathering information through channels stipulated in the nuclear disaster response manual.

— did not use in issuing evacuation orders data from a computer system to predict the dispersal of released radioactive materials.

— failed to fully use a facility planned to serve as the local headquarters as it was unprepared for a rise in radiation levels.

TEPCO:

— misunderstood the functioning status of the No. 1 reactor’s cooling system called the isolation condenser.

— had not trained reactor operators sufficiently to handle the isolation condenser.

— mishandled the No. 3 reactor’s emergency cooling system.

— might have been able to lessen the damage of fuel inside the Nos. 1 and 3 reactors if it acted more appropriately.

The investigation committee:

— calls for the need to be prepared for low-probability events if the possible consequences could cause extremely huge damage.

— calls for the need to consider the possibility that a nuclear accident can occur in combination with natural disasters.

— believes that people involved in considering the country’s nuclear disaster measures lacked a broader perspective on the issue.

— has so far not confirmed that reactor vessels were damaged by the March 11 earthquake, before being hit by ensuing tsunami waves.

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NISA ’powerless to handle severe accident’ / Interim report: Agency merely urged TEPCO to provide information, failed to control situation
Shin Watanabe, Yomiuri Shimbun Staff Writer, December 28, 2011
http://www.yomiuri.co.jp/dy/national/T111227003729.htm

An interim report released Monday by a government panel investigating the crisis this year at the Fukushima No. 1 nuclear plant stated that the Nuclear and Industrial Safety Agency (NISA) and other governmental organizations failed to deal with the crisis effectively in their respective capacities and also failed to cooperate with each other.

Ahead of the establishment in April 2012 of a new regulatory body to oversee nuclear safety, many problems with NISA have been revealed.

The interim report by the government’s investigation committee said the agency could hardly fulfill its function as the supervisory body in the wake of the accident, referring to its lack of self-awareness in dealing with the issue and actively collecting relevant information.

After the crisis began, the agency played the role of secretariat of the Nuclear Emergency Response Headquarters set up at the Prime Minister’s Office. It should have become the core organization for gathering information from various organizations, such as the power plant and its operator, Tokyo Electric Power Co.

However, immediately after the accident, NISA relied on information obtained by staff dispatched by TEPCO’s head office to the agency. The staff members got the information from TEPCO’s head office by cell phone.

At that time, TEPCO’s head office shared information with the local headquarters in Fukushima Prefecture in real time through a videoconference system.

But the agency did not dispatch its officials to TEPCO’s head office, which is only about 600 meters away from the agency’s office.

As the agency could not obtain sufficient information about the ongoing situation, the Prime Minister’s Office apparently initiated its own direct contacts with TEPCO executives and the nuclear power plant staff. This situation led to a muddying of the command channels.

NISA’s nuclear safety inspectors, who should have played the role of nuclear watchdog, apparently lacked a strong will to deal with the crisis.

During the accident, four inspectors were at the nuclear power plant. But they temporarily evacuated around 5 a.m. on March 12. They returned to the plant the next morning, but left again on the evening of March 14 because of a hydrogen explosion at the No. 3 reactor before noon that day.

The interim report severely criticized NISA’s instructions to TEPCO as having little influence on decision-making at the nuclear power plant, as most of the agency’s instructions went no further than urging TEPCO to provide correct information as soon as possible.

Yohishiro Nishiwaki, a visiting professor at the University of Tokyo and former director of the agency’s nuclear power inspection division, said: “It’s difficult to deal with severe accidents without extensive and sufficient knowledge. But ordinary safety regulations by the agency mainly aim at preventing severe accidents [rather than dealing with severe accidents].”

“The agency lacked both human resources and knowledge to respond to the emergency,” Nishiwaki added.

Regarding a new nuclear safety agency set to succeed the current agency, the interim report stated: “It is necessary to develop professional competence to provide appropriate advice and leadership to the responsible personnel and relevant organizations that are in charge of emergency response.”

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Poor communication blamed

The interim report also found the Prime Minister’s Office caused greater confusion by making important decisions without sufficient consultations with concerned organizations.

As an example, the interim report described how then Prime Minister Naoto Kan responded to the injection of seawater into the No. 1 reactor on the night of March 12, one day after the Great East Japan Earthquake. He was later criticized for trying to stop the operation out of concern that it would cause a recriticality at the reactor.

According to the interim report, the crisis management center in the basement of the Prime Minister’s Office was already aware that the power plant had started the sea water injection when Kan and other top government officials—in the prime minister’s working room on the fifth floor—were still discussing concerns about the possible recriticality without being informed of the fact.

The interim report suggested such confusion could have been prevented if the people in the prime minister’s working room and the crisis management center had sufficient communication with each other.

While continuing the discussions, Kan issued an instruction at 6:25 p.m. on March 12 that the evacuation zone should be expanded to a radius of 20 kilometers around the plant from the initially designated 10 kilometers.

The interim report found the decision also was related to concerns about the possible recriticality, but the order was issued without consulting concerned ministries and agencies or local governments.

Areas outside the 10-kilometer zone had not been subject to emergency drills before the outbreak of the crisis. Therefore, authorities were not prepared at all to evacuate residents in the newly designated zones. Procedures for briefing concerned local governments and securing shelters were among the missing elements.

As a result, local governments near the crippled plant were forced to decide how to evacuate residents without sufficient information, according to the interim report.

“Residents [near the plant] eventually became very distressed by the mixed messages they were getting,” the report stated.

Nobuo Ishihara, who served as deputy chief cabinet secretary at the time of the 1995 Great Hanshin Earthquake, described disaster response as “a battle against time.”

“Therefore, the government has to gather all information in an integrated manner,” Ishihara said. “The Democratic Party of Japan-led government might have failed to sufficiently communicate with bureaucrats [following the quake] under its slogan of politicians taking the initiative in carrying out policies.”

Kyodo Press, December 26, 2011
http://mdn.mainichi.jp/mdnnews/national/archive/news/2011/12/26/20111226p2g00m0dm113000c.html

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