Report of Findings
by the External Expert Panel to Review the Radioactive Material Leak Accident
at the Hadron Experimental Facility of J-PARC

August 22, 2013
“The External Expert Panel to review the Radioactive Material Leak Accident at the
Hadron Experimental Facility of J-PARC” (hereafter “the Panel”) has completed this Reportconcerning the validity of proposals formulated by the J-PARC Center to prevent recurrence of
the accident that occurred at J-PARC on May 23, 2013, as well as the center’s efforts to review
its safety management framework and emergency procedures. The Report was prepared in
response to the following inquiries that were submitted by the heads of the Japan Atomic
Energy Agency (JAEA), and the High Energy Accelerator Research Organization (KEK), which
oversee the J-PARC Center.
Inquiries(1) Review of safety management system and emergency procedures at the J-PARC Center(2) Evaluation of the validity of the accident measures developed by the J-PARC Center

1. Accident examination and issues
To efficiently promote examination and evaluation of inquiry items (1) and (2), the Panelestablished a working group (WG) comprised of four experts and received its detailed report asshown in the attached report. An outline of the examination that was conducted based on the
WG report and identified issues are presented below.

(Outline of the accident)
At around 11:55 A.M. on May 23, 2013, a power supply to two electromagnets in the
50-GeV synchrotron (MR) for slow (continuous) extraction of a 30-GeV proton beam to the
Hadron Experimental Facility (hereafter HD facility) experienced a very brief malfunction of
unknown cause. Due to this malfunction, a high intensity pulsed beam that was far in excess
of designed parameters was hit the gold target for a moment. Although the gold target wascooled, its cooling capability was insufficient to handle the heat load being applied by the high1

intensity beam. Thus, it is considered that the gold instantaneously melted along the beamaxis and consequently various types of radioactive material that were generated within thegold target vaporized. It is believed that, because the container encasing the gold target was
not hermetically sealed, the radioactive material’s vapor diffused into the primary beamline
area (class 1 radiation controlled area 1) and that, further, because the air of this area wasunder positive pressure, the vapor passed through gaps between concrete radiation shielding
blocks and leaked into the Hadron experimental hall (HD hall) (class 2 radiation controlledarea 2), where many researchers were at work. Some of the workers noticed abnormal figureson area monitors that installed in the HD hall. However, they suspected that the monitors
were malfunctioning. As they attempted to verify this, they released air of the HD hall tooutside areas through ventilation fans. It subsequently took time until workers gained acorrect understanding that the hall’s air was contaminated with radioactive material, and thus
reporting the situation to the relevant authorities including local governments was delayed.
Moreover, workers who were late in evacuation inhaled the radioactive material andconsequently received internal radiation doses.

(Problems and arising issues)
Problems associated with the accident can be summarized into three areas: 1) leakage ofradioactive material, 2) delay in reporting to relevant authorities, and 3) radioactive exposureof workers.
Issues arising from the leakage of radioactive material are grouped into two categories,
such as those regarding facilities and those regarding safety management system.
Facility-related issues include the electromagnet’s malfunction, insufficient hermetic sealing,
and inadequate ventilation equipment.

Safety management-related issues include an

inadequate safety review system and therefore overly optimistic assumptions concerning
anomalies, errors in judgment that led to operation of the ventilation fans, and inadequate
procedures for restarting beam operation.
Regarding the delay in reporting, issues include insufficient information collection andpoorly developed criteria for judgment, misunderstanding of laws and ordinances, and an
inadequate command system that resulted in the absence of managers and non-appointment of
1: Area in which control of contamination of surfaces and air from radioactive material is required.
2: Area in which control of contamination of surfaces and air from radioactive material is not
required.
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representatives.

These factors hindered an organizational response and led to delays indecision-making.
Factors behind the radioactive exposure of workers include deficient radioactivity alarms,
inadequate evacuation standards, a poor system for sharing information, and inadequate
education.
(Preventive measures against recurrence)
Tables 1 and 2 summarize the preventative measures, safety management system, andemergency procedures based the issues and subject matters.

Table 1: Correspondence between hardware-related arising issues and preventive measuresagainst recurrence
Problems

Leakage ofradioactive
material

Delay in reporting
to relevant
authorities

Arising issues

MeasuresMalfunction ofelectromagnets• Reinforcement of interlock system (prevention of
overcurrent, etc.)• Faster interlocking system

Insufficienthermetic
sealing• Making the target container airtight• Reinforcing airtightness of the primary
beamline area

Inadequate
ventilationequipment

Venting the air in the HD hall through filters while
monitoring concentration of radioactive material in
the air―

Inadequate
Radioactive
radioactive
exposure of workers
alarm system―
Improving the monitoring system to observe
radiation level in J-PARC facilities

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Table 2: Correspondence between subject matters concerning the safety management systemand preventive measures against recurrence
Problems

Leakage ofradioactive
material

Arising issues

Measures

Inadequate safety
review system

Reinforcement of the radiation safety
review system

Ambiguous criteria forjudgment

Review of the framework to respond to ananomaly (introduction of the “alert status”)
Improvement of operating manuals

Ambiguousdescription ofprocedures forrestarting beam
operation

Improvement of operating manuals

Insufficient
information collection

Review of the framework to respond to ananomaly (introduction of the “alert status”)

Review of the framework to respond to an
Insufficient criteria foranomaly (introduction of the “alert status”)
making judgment
Improvement of operating manuals
Delay in reporting
to relevant
authorities

Radiation exposureof workers

Misunderstanding oflaws and ordinances

Review of the framework to respond to ananomaly (introduction of the “alert status”)
Appointment of a Deputy Director to
oversee safety

Inadequate command
systemReview of the framework to respond to ananomaly (introduction of the “alert status”)
Appointment of a Deputy Director to
oversee safety

Ambiguous criteria forevacuation

Review of the framework to respond to ananomaly (introduction of the “alert status”)
Improvement of operating manuals

Poor system for
information sharing

Review of the framework to respond to ananomaly (introduction of the “alert status”)

Poor system for safety
education

Enhancement of employee education anduser education(Impact on the surrounding environment and radioactive exposure of workers)
As is stated in the report from the WG, the radioactive material leak accident had
sufficiently small impact on the environment (maximum of 0.29 μSv 3) and no health impact

3: Equivalent to ~1/3400 of the annual limit of radiation dose for members of the public
recommended by the International Commission on Radiological Protection (ICRP) .
(1 mSv = 1,000 µSv)
4even in the case of internal exposure (maximum of 1.7 mSv 4). However, the accident exposed
low awareness of safety and inadequate safety management system of the J-PARC Center as
pointed out by the Minister of Education, Culture, Sports, Science and Technology.
(Risk assessment at three facilities other than the HD facility)
In addition to the HD facility, J-PARC includes the Materials and Life Science
Experimental Facility, the Neutrino Experimental Facility, and the Accelerator Facility. The
Panel also reviewed these facilities in terms of the appropriateness of their radiation control
areas and managing systems, and safety of their equipment. It concluded that radiation
control areas were appropriately established and managed and that equipment safety was
sufficiently high at the three facilities.

2. Improvement plan to be executed by the J-PARC Center
The J-PARC Center proposed the following three core approaches as well as measuresand an improvement plan that are based on the above-mentioned identified issues and geared
toward their resolution to the Panel.
1. Building of an organization and system that makes safety the highest priority
2. Developing an action manual that instills safety awareness through all parts of all
facilities
3. Cultivating a culture for sustained development of safety(1) The safety management system and emergency procedures
1) Cultivating a safety culture under the responsibility of Director of the J-PARC Center
The J-PARC Center will strive to cultivate a safety culture that permeates
throughout the center by clarifying safety objectives for the center and repeatedly
providing education and training to maintain and improve safety awareness among all
staff members. The learning level of the members will be evaluated to enforce ingraining
the safety culture in the J-PARC Center. Efforts to cultivate this culture will take place
under the leadership of Director of the J-PARC Center, who will have a full responsibility
for safety at the center.

4: Equivalent to ~1/30 of the annually allowable radiation dose of radiation workers
established by law (50 mSv).
52) Organizational reformation for thoroughgoing attention to safety
The J-PARC Center presented the concept for organizational reformation to
overcome the issues mentioned in the previous section (Figure below). The a), b), and c)in the figure refer to the three points of the organizational reformation.

a) Creating a new position of a Deputy Director to take charge of safety throughout
J-PARCThe J-PARC Center will build a framework that seeks to integrate safety
reinforcement efforts throughout the center. The framework includes creation of a
new Deputy Director position to uniformly implement radiation safety management
in all J-PARC facilities and take overall command of responses to anomalies as well asplacement of the Safety Division under this deputy director.

The newly installed

Deputy Director to take charge of safety at J-PARC will be an employee possessing highawareness and deep knowledge of safety and serve as a “control tower” for safety in
J-PARC. The J-PARC Center will endeavor to appoint the most qualified person forthe post by looking both inside and outside the center.

6b) Clarification of persons in charge during emergencies at each facility
In an emergency situation, a Facility Manager of each facility will direct a task
force and the newly appointed Deputy Director will be in charge of safety in an overall
supervisory position. It will build a safety management system (the figure above) thatclarifies jurisdictions and an integrated chain of command. It will also establish aframework that can make specific responses during emergencies by appointing persons
in charge beforehand and conducting repeated training.
c) Reinforcement of radiation safety evaluations in J-PARC
To reinforce an evaluation function concerning facility and equipment safety
standards and radiation safety standards (e.g., manual revisions, etc.), the J-PARC
Center will reorganize the existing “Internal Radiation Safety Committee”, which has
primarily been a body of rank-designated members of the J-PARC Center, into a
Radiation Safety Review Committee to be comprised of experts (including external
advisers) and build a framework for conducting thorough and specialized radiation
safety evaluations.
3) Development of a response system for anomalies and clarification of criteria for judgment
To initiate emergency responses precisely and quickly, the J-PARC Center will
introduce a new level called “alert status” between the existing “normal status” (ordinary
situation) and “emergency status” (occurrence of an event requiring reporting). At thisnew status, the Facility Managers and persons involved will be called together when
symptoms of an accident first appear in order to make an organized response. Leaders
under this warning status (i.e., Facility Managers and their representatives) should make
J-PARC their main base of their work in order to ensure precise and quick responses.
The J-PARC Center will also revise operating manuals with clear criteria for judgment toensure that judgments are made quickly and unfailingly during anomalies.
The J-PARC Center will immediately notify all personnel within J-PARC as well as
local governments and others concerned whenever an emergency occurs.
4) Reinforcement of safety education for users
The J-PARC Center will provide users with appropriate safety education inaccordance with the circumstances of each facility and develop awareness among not only
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J-PARC staff members but also users on the need to improve safety.
(2) Measures against similar accidents
Because absolutely eliminating equipment malfunctions is difficult even if all possible
measures are implemented, the J-PARC Center will execute improvement measures tominimize damage if a malfunction occurs.

Specifically, it will implement all possible

measures to prevent malfunctions, take steps to minimize radioactive material leaks even if
the target is damaged, and ensure that absolutely no radioactive material is leaked outside ofradiation controlled areas of the facility.

To achieve these aims, it will implement thefollowing multi-layered measures.
1) Take measures to deal with malfunctions of the 50-GeV synchrotron electromagnets(such as prevention of over current, etc.).
2) Place the target of the HD facility in a hermetic container and strengthen the
air-tightness of the primary beamline boundary.
3) Constantly monitor the air in the HD hall and pass it through filters when releasing it.
4) Revise and improve monitoring systems for observing radiation level in the J-PARC
facilities.
The J-PARC Center will proceed with improvements to the HD facility based on theabove-mentioned measures, paying full attention to ensure that secondary accidents do notoccur.

3. Report of Findings
The Panel submits the following report prepared from the results of its deliberations of
the preventive measures proposed by the J-PARC Center to the heads of JAEA and KEK.
(1) Confirmation of the safety management system and emergency procedures
The Panel evaluates the measures to be implemented by the J-PARC Center as follows:
1) Cultivating safety culture under the responsibility of Director of the J-PARC Center
Subject matters that were identified in connection with the accident include issues
in the organizational response (specifically, a deficient chain of command), ineffective
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response to anomalies and poorly developed criteria for judgment, and overly optimistic
evaluation of facility and equipment safety. The cause behind these issues is thought tobe deficient safety awareness throughout the J-PARC Center as an organization.
The Panel confirms that the above-described measure “cultivating culture of safety
under the responsibility of Director of the J-PARC Center” includes establishment ofsafety awareness as well as provision of education and training for appropriate staff
members to resolve the problems mentioned above.

The Panel therefore deems thismeasure to be appropriate.
2) Organizational reform for thoroughgoing attention to safetya) Assignment of a person to take charge of safety throughout the J-PARC Center
The causes of insufficient information collection, poorly developed criteria forjudgment, and misunderstanding of laws and ordinances that led to the delay instatutory reporting; the errors in judgment that led to operation of the ventilation fans,which caused the leakage of radioactive material; and the poor system for sharing
information on radiation exposure for workers can be found in the fact that current
responses to anomalies depend upon a facility. No center-wide system for appropriate
information collection and decision-making is in place, and thus the center cannot
handle events such as the relevant accident that involve multiple facilities.
The Panel finds that the above-described measure “assignment of an officer(Deputy Director) to take charge of safety throughout the J-PARC Center” will realize
integrated safety management throughout the center and is thus appropriate.
b) Clarification of persons in charge during emergencies at each facility
The accident revealed an inadequate command system.

Because it was notclearly established that the Facility Manager of each facility became the person in
charge of that facility at an emergency, Facility Managers were not present at the timeof the accident. Moreover, no representatives were assigned to act for absent Facility
Managers.
The Panel finds that the above-described measure “clarification of persons incharge during emergencies in each facility” is capable of maintaining an effectualcommand system all the time and is thus appropriate.

9c) Reinforcement of radiation safety evaluation in J-PARC
The accident brought into relief the poor development of guides concerningfacility and equipment matters and safety management. There is no getting aroundthe fact that this was the result of inadequate supposition of anomalies that can lead toradiation accidents and insufficient technical discussions in radiation safety evaluation
process at J-PARC. More specifically, it was caused by functional problems in theInternal Radiation Safety Committee, which currently conducts reviews/evaluations ofradiation safety issues at J-PARC.
The Panel finds that the above-described measure “reinforcement of radiation
safety evaluations in the J-PARC Center” will be essential in realizing safety in termsof both hardware and software and is thus appropriate.
3) Development of a response framework for anomalies and clarification of criteria forjudgment
The current manual on safety management presents guidelines for responding toanomalies when the discoverer of an event is capable of identifying it as an accident.
However, it does not envision events like that addressed in this Report that demand
accurate ascertainment of anomalous “symptoms” when circumstances are changing frommoment to moment.

This led to the delay in statutory reporting and misjudgments

concerning the radioactive material leak.
The Panel finds that the above-described measure “development of a response
framework for anomalies and clarification of criteria for judgment” — specifically, theestablishment of the new “alert status” and development of manuals that clarify criteria
for judgment — is appropriate.
4) Reinforcement of safety education for users
At the time of the accident addressed in this Report, there were many users who
were not evacuated despite being aware of the rising radiation level. J-PARC is a globally
advanced research facility that brings together many researchers from inside and outside
Japan. Accordingly, ensuring the safety of J-PARC absolutely requires that not only staff
members but also this broad range of users keep safety firmly in mind and be fully
cognizant of necessary responses.
The Panel finds that the above-described measure “reinforcement of safety education10

for users” will be effective in raising awareness among users and is thus appropriate.
(2) Confirmation of validity of accident measures plan
The Panel finds the following accident measures plan that was proposed by the J-PARC
Center to be valid and urges its immediate execution.
The J-PARC Center will:
1) take measures to deal with malfunctions of the 50-GeV synchrotron electromagnets(such as prevention of overcurrent, etc.),
2) place the target of the HD facility in a hermetic container and strengthen the
air-tightness of the primary beamline boundary,3) constantly monitor the air of the HD hall and pass it through filters when releasing it,and4) improve monitoring system for observing radiation doses within the J-PARC facilities.

4. Other matters and recommendations produced from deliberations
In addition to the producing the findings presented above, the Panel conducted
deliberations and evaluations that took into account several basic standpoints.
J-PARC is a research facility that was constructed with the globally oriented objective of
producing cutting-edge science and technology research achievements using high-intensity
proton beams. The J-PARC accelerators and experimental facilities have the responsibility ofproviding research opportunities to numerous researchers, including users from overseas.
Thus, the early restart of their operation will meet the expectations of the public in Japan andalso overseas researchers.
However, it must also be remembered that J-PARC can only fulfill its mission as aninternational public asset if it secures peace of mind in the local community as well as public
understanding. This requires the establishment of shared recognition within the J-PARC
Center that the safety of the local community, users, and staff members comes before researchvalue and efficiency. At the same time, gaining understanding from local communities will
require efforts oriented toward natural cultivation of deeper mutual understanding and trust.
This should be achieved with not only routine publicity through public relations activities but
also active utilization of activities that bring people face-to-face with J-PARC staff members.
Such activities could include creating opportunities for dialogue on research with local
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students and other members of society.
Based on these observations, the Panel recommends the following to the heads of the
JAEA and KEK.
1) Measures should be implemented side-by-side with efforts to fully explain the causes of
the accident and preventive measures against recurrence to local communities and to
gain their understanding.
2) Greater attention should be given to local communities when reporting accidents, and afaster statutory reporting and communications framework should be established.
3) The Panel recommends that evaluations of the safety of the new hadron target andrestart of operations at the HD facility be subjected to external evaluation. The Panelhas determined that the setting of radiation control areas at facilities other than the
HD facility (namely, the Accelerator Facility, Materials and Life Science Experimental
Facility, and Neutrino Experimental Facility) and their management are being
executed appropriately, and that the safety of devices/equipment to handle severe
events is assured. The Panel believes that it will be appropriate to restart thesefacilities when the new safety management system is in place, prescribed procedures
are completed, and local communities’ understanding is obtained.
4) Under the leadership of Director of the J-PARC Center, safety culture must be
cultivated to improve safety awareness among organizations concerned with theoperation of facilities throughout the center as well as staff members and users and topromote safe behavior. The Panel presents the following concrete proposals intended
to strengthen this activity.
・ Among other items, formulate (1) a safety policy and (2) behavior guidelines asbasic policies for facility operation. Study having staff members and users carry
cards noting the safety policy, behavioral guidelines, and actions to be taken in
emergencies as a means of fostering constant awareness of them.
・ In order to clarify latent risks that can cause anomalies and accidents,− continue efforts to expand the scope of foreseeable anomalies,− conduct risk assessment,− study the effects and root causes of troubles and near-misses that occur in daily
operations and evaluate repercussions on other facilities,− encourage staff members and users to make suggestions or comments that help
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improve safety, and build a mechanism that allows them to report problems they
simply notice or have concerns about at any time, and− require users to note suggested or desired improvements when filling out theirpost facility-use reports.

5. Summary
In response to inquiries from JAEA and KEK, the Panel reviewed the safety
management system and procedures to be carried out in emergency situations that were
presented to it by the J-PARC Center in connection with the recent accident in J-PARC anddiscussed the accident measures. The Panel concluded that each of them is appropriate andhereby reports this conclusion to both heads.
The Panel expects the J-PARC Center to build an organization and a framework that areprimarily oriented toward ensuring safety by immediately executing the content of this Report
as it also seeks to gain the understanding of its local communities and society at large. The
Panel also expects J-PARC to quickly return to a state in which it can produce cutting-edge
research achievements so that it may meet the expectations of public in Japan and overseas
researchers.

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