Lessons Learned
from the Fukushima Dai-ichi Accident
regarding Safety Culture of Regulatory Body

Toyoshi Fuketa
Nuclear Regulation Authority
NEA/CNRA/CSNI/CRPPH Joint Workshop on
Challenges and Enhancements toSafety Culture of the Regulatory Body
UICP, 16 rue Jean Rey, Paris, June 3, 2015

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In lieu of Introduction

XII. Lessons Learned From the Accident Thus Far(28) Thoroughly foster safety culture

Report of Japanese Government
to IAEA Ministerial Conference on
Nuclear Safety, June 2011

All those involved with nuclear energy should be equipped with safety
culture. … Without safety culture, there will be no continuous
improvement of nuclear safety.
(The operators) … should take a hard look at whether they have been
serious in introducing appropriate measures for improving safety, when
they are not confident that risks … remain low. Priority to safety
Also, (the regulators), … as those who responsible for … safety of thepublic, should take a hard look at whether they have been serious inaddressing new knowledge in a responsive and prompt manner, notleaving any doubts in terms of safety. Agility… Japan will establish a safety culture .., namely that pursuingdefenses-in-depth is essential for ensuring nuclear safety, … and by
maintaining an attitude of trying to identify weaknesses as well as
room for safety enhancement.

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Diet and Government reports wrote:

National Diet’s Report [1]:The TEPCO Fukushima NPP accident was the result of collusion
between the government, the regulators and TEPCO, and the lack ofgovernance by said parties. They effectively betrayed the nation’s right tobe safe from nuclear accidents. Therefore, we conclude that the accident
was clearly “manmade.”Lack of regulatory independence “Regulatory Capture”
Government’s Final Report [2]:… reveals a fundamental problem of the inability to capture such crises
as a reality that could happen in our lives; this, in turn, is the result of asafety myth that existed among nuclear operators including TEPCO aswell as the government, that serious severe accidents could never occur
in nuclear power plants in Japan.
[1] Report from NAIIC (the National Diet’s Fukushima Nuclear Accident Independent
Investigation Commission), July 5, 2012
[2] Final Report from The Government’s Investigation Committee on the Accident atFukushima Nuclear Power Stations of Tokyo Electric Power Company, July 23, 2012

3Cultural Bias

NRA

Message from NAIIC Chairman

National Diet’s Report

For all the extensive detail it provides, what this report cannot fully
convey – especially to a global audience – is the mindset that supported
the negligence behind this disaster.
What must be admitted – very painfully – is that this was a disaster“Made in Japan.” Its fundamental causes are to be found in theingrained conventions of Japanese culture:
our reflexive obedience;
our reluctance to question authority;
our devotion to ‘sticking with theprogram’;our groupism; andour insularity.

Look universal

May produce another safety myth

NRA“Complacency” together with “Bureaucracy” allow “Safetymyth” to prevail, letting “Continuous improvement” cease.
Institutional failures
Cognitive bias
Bureaucracy

Safety myth prevailed
Complacency

Lack of independenceContinuous improvement ceased

Isolation
Lack of agility
Missed the chances
Sending later

Collapse4

5NRACognitive Bias
We tend to have positive illusions that lead us toconclude that a problem doesn’t exist or is not severe
enough to merit action.
We overly discount the future, reducing our courage toact now to prevent some disaster that we believe to bequite distant.
The fact is that decisions concerning the future will
always contain some degree of uncertainty. Uncertainty
allows for wishful thinking, but reality is too often deaf to
our wishes.
Bazerman, M. H., and Watkins, M. D., “Predictablesurprises”, Harvard Business School Press, 2004.

6Safety MythNRA

Zero risk illusion
Easiest way that started to persuade stakeholders
Regulators became involved, though they should not havebeen done.
They themselves trapped by “Safety myth” and captured tothink consistently with it.

Safety myth brought about:“Sending later” attitude, Lack of agility
Go the easy way, easy option
Loss-of-self criticism, complacency
Loss-of learning attitude, Isolation
Lack of comparison, avoid lift each other up“all the facilities are equally safe”“Safety myth” goes with “Bureaucracy”

7NRA“Safety myth” brought about, e.g.

Following the approval of the draft IAEA safety guide GS-G-2.1, the NSC
held the first meeting of the WG for Reviewing the EPR Guide in Marchin 2006 ....
The WG initially aimed to introduce the concept of PAZ (PrecautionaryAction Zone). However, the WG met with a strong opposition fromNISA… :… in Japan it was extremely unlikely that a serious accident leading
to a release of large amount of radioactive materials would occur;…there was no need to immediately evacuate residents within a 5km radius… “Safety Myth”… if IAEA’s approaches … are introduced, … the local residents
there would be forced to consider relocation … ; this would causesignificant social confusion and foster a perception that the existing… measures based on EPZ is insufficient …
“Don’t wake asleeping child”, “Bureaucracy”, etc.
Government‘s Final Report

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Easy Option
From number of years ago, some experts in the field of
severe accident and emergency preparedness andresponse keep questioning the decision-making system intaking protective actions under emergency by overlyrelying on source term prediction and dose projection
systems.
“Source term prediction at emergency is precise andreliable enough” was another safety myth. Those systems
were an easy option for many.

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Missed the Opportunities

Against SBO

National Diet’s Report

Following the implementation of new regulations in the U.S. in 1988…,
the NSC in 1991 set up the WG on SBO under the NSC’s Committee on
Operating Experience Feedback… concluding that the probability of an SBO occurring was low… The
report did not make any recommendations on incorporating SBO in theSafety Design Guide …

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Lack of Agility
Merriam-Webster “Agility”
marked by ready ability to move with quick easy grace
having a quick resourceful and adaptable character
http://www.merriam-webster.com/dictionary/agile

Tsunami risk recognized
National Diet’s Report

By 2006, NISA and TEPCO shared information on the possibility of a
SBO occurring at the Fukushima Dai-ichi plant .... They also shared anawareness of the risk of potential reactor core damage from a loss ofseawater pumps …
… NISA was aware of TEPCO’s delaying of countermeasures, but did
not follow up with any specific instructions or demands. Nor did they
properly supervise the backcheck progress. Lack of Agility
When new findings indicate the possibility of a tsunami exceeding
previous assumptions, the operator…. is required to quickly implement
countermeasures, rather than taking time to clarify the scientific basis…

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Omission Bias and the Status Quo
We tend to maintain the status quo, and refuse to accept
any harm that would bring about a greater good.
As a society, we are much more prone to make errors ofomission (doing nothing) than errors of commission(causing harm).
Bazerman, M. H., and Watkins, M. D., “Predictablesurprises”, Harvard Business School Press, 2004.

They (operators and regulatory agencies) chose instead
to go the easy way, with the attitude: “Don’t disturb asleeping baby.” They … were meek in their efforts totackle the issues...with a sense of urgency.
Altogether, this was nothing less than bureaucratic inertia- which is incompatible with a safety culture.

National Diet’s Report

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Institutional Failures
Incentive failures occur when people in the organization
have the requisite insight needed to prevent emerging
problems, but fail to do so … because they lack an
incentive to take action …
Prioritization failures arise when leaders and organizations
recognize potential threats but do not deem them sufficient
to warrant serious attention.
Failure to devote necessary resources
Bazerman, M. H., and Watkins, M. D., “Predictablesurprises”, Harvard Business School Press, 2004.

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Structural Problems… promotion of nuclear power came first in importance. … Therein lies
the fundamental reason why the formulation and development of asound safety culture was hampered.
… for Japan’s regulators, “promotion” considerations took priority overintroducing new regulatory measures. They feared that new regulations
might call into question the validity of the safety measures that were inplace, raise the risk of defeat in lawsuits by anti-nuclear advocates, ordraw the unwelcome attention....
They stuck to their belief of infallibility so much that they were reluctant
to improve safety regulations…
National Diet’s Report

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Oblivious
Criticality accident at JCO plant in 1999
The root of this accident was lack or erosion of “crisis awareness” ofcriticality accident. …it is important to keep it in mind… To prevail thiscrisis awareness in our society, we must change our consciousness
from "safety myth" or "absolute safety" into “risk informed safetyassessment”.
NSC’s Report on JCO criticality accident
at Tokai-mura, Dec. 1999

Loss of institutional memory
Lapses in capturing lessons-learned, and long-term erosion of thefabric of institutional memory due to personnel losses
Bazerman, M. H., and Watkins, M. D., “Predictablesurprises”, Harvard Business School Press, 2004.

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NRA’s Efforts to foster Nuclear Safety Culture
NRA’s Core Values and Principles, Jan. 2013
Transparency through live video on the web and disclosure ofdocuments• Clear message from NRA Chair on “no more safety myth”.
• Attitude to seek for safety improvement through conformance
review meetings with licensees
Enhancement of technical infrastructure within the NRA• Operational feedback with agility, e.g., the loss of one of the threephases of the offsite power circuit at Byron Station.
• Human resource development: recruit and training, regulatory
research programs
International peer reviews:• IPPAS in Feb. 2015 and IRRS in Jan. 2016: use as opportunities
for identifying the areas for further improvement

NRA’s Statement of Nuclear Safety Culture
NRAIssued on May 27, 2015

Structure of NRA’s Mission Statements in its Management System
NRA’s Core Values and Principles
Statement ofNuclear Safety Culture

Code of Conduct
on Nuclear Security

Eight Traits of Nuclear Safety Culture in NRA’s Statement
1. Priority to Safety
Break with “safety myth”
2. Decision-making prioritized by safety
3. Fostering, sustaining and strengthening safety culture
4. Organized learning
Seek out “opportunities for improvement”
5. Communication
Get rid of “isolation”/”self-righteousness”
6. Questioning attitude
Avoid “complacency”
7. Rigorous and prudent judgment and action with agility
8. Harmonization with nuclear security

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NRAInternational Community
Japanese attendees in most international meetings …
Not participating but just attending
Few incentive in officials of the regulatory body
The NRA, now, tries to choose the right person to the right meeting, tolearn from discussions, and to be a real active member in international
communities. The NRA has proposed and/or taken a lead of theOECD/NEA activities, such as:
BSAF (Benchmark Study of the Accident at the Fukushima Daiichi
Nuclear Power Plant ) Project
CSNI SAREF (Senior Expert Group on Safety Research
Opportunities Post-Fukushima )18NRAClosing remarks

The NRA was designed and established as an independent regulatory
body in Japan based on lessons learned from the Fukushima Dai-ichi
accident. The NRA has been working intensively with thoroughtransparency, and recently issued a statement of nuclear safety culture.
The accident keeps being a distinct memory at present. All the NPPs arestill shut-down status, and nation-wide, furious discussions about re-start
are going on. Accordingly, activities in the NRA get a lot of attention, andsense of mission, sense of responsibility in NRA members is quite vivid in
their mind.
We, however, acknowledge we are oblivious. We must incorporate
lessons-learned into the “institutional memory” of the NRA.
Numerous sprouts of safety myth reappear already. We still face
problems and difficulties in incentive and prioritization. It is absolutely
inevitable for us to keep having self-questioning attitude for safety culture.
We must create an environment where a gene letting us think “safetyfirst” can survive.

With thanks to
Masashi Hirano
Masahiro Aoki
Masami Takita
Hiroko Koike
NRA