Overview
1. Introduction
The Japan Nuclear Technology Institute (hereinafter “JANTI”) conducted apeer review (hereinafter “review”) with a review team comprising members
and specialists from JANTI. The team visits member offices and conducts areview on themes related to nuclear power safety to extracts issues and goodpractices from which other members can learn from. Goals of review
activities are to bring a greater awareness of safety and achieve
improvements in safety culture in the nuclear industry wide.
2. Overview of Subject Locations
The Mitsubishi Heavy Industries, Ltd. (MHI) Takasago Factory (hereinafter“The Factory”) commenced operation in 1962 as a factory dedicated to producing
turbines as part of Kobe Shipyard & Machinery Works, but became a separate entity in
1964.
Presently part of MHI, The Factory is dedicated to the production of large-scalerotating equipment, and produces steam turbines, gas turbines, pumps and water wheels,etc. for nuclear power and thermal power stations which provide the electricity that is
the foundation for living and industry.
The Factory engages in the design, manufacture, installation and after-sales
service, etc. of equipment, such as turbines, condensers, feedwater heaters, and pumps
that make up the secondary systems of nuclear power stations.
The nuclear power turbines for all 23 pressurized-water reactors (PWR) in
Japan were manufactured by The Factory. When overseas exports are added, The
Factory has been responsible for the construction of 25 nuclear power turbine plants that
produce 20.72 million KW of electricity.
It is presently manufacturing Hokkaido Electric Power Co., Inc. Tomari Power
Station Unit 3, and the Japan Atomic Power Company Tsuruga Power Station Unit 2
turbines.
As of April of this year, The Factory had 3,400 employees and 6,200 if
subcontractor employees around Takasago are added.
3. Approach and Point of Review

This review focused on quality assurance efforts linked to corporate
management, communication between upper management and employees, and nuclear
power safety as they relate to the design and manufacture of nuclear power equipment at
The Factory.
In addition to the three themes of “organization/management,”“education/training,” and “design/manufacturing”, “human error prevention,” which
JANTI considered to be an important issue, was examined. In the review, JANTI put
effort into finding those points that would be useful as reference for other members
while keeping in mind the nuclear power station equipment designed and manufactured
at The Factory.
4. Conducting the Review(1) Review period
Wednesday, June 20 - Friday, June 22, 2007
(2) Composition of review teamTeam leader: JANTI NSnet Division personnel
Team members: 4 persons under the team leader(Japan Nuclear Fuel Limited: 1, Mitsubishi Materials Corporation: 1, JANTI NS Net
Division personnel: 2)(3) Review team assigned areas
Group A: Organization/Management, Human Error Prevention
Group B: Education/Training, Design/Manufacturing
5. Review Schedule
The review lasted three days and each group proceeded in accordance with thefollowing schedule which has been simplified.

Implementation Schedule
Group AGroup B(organization/management, human error prevention)(education/training, design/manufacturing)

Wednesday,

AM

Opening (greeting, member introduction, explanation of latest news about the factory, etc.)

June 20PM

I.

Factory Director

Organization/management-Organization

safety/quality

policies/objectives

improvement PJ-Leadership

Working

Interview

Event/site observation

Nuclearsubcommittee

power

On-site144th

patrolII. Education/training

Education/training-LeadershipIII.

planning(-initiative/awards

Design/manufacturing

implementation

I.

Manager class

Organization/Management

Interview

scope

and

Design management-objectives/clarificationofDocumentsofresponsibility-safetymessagedissemination)-Quality

assurance

program-Efforts

regarding

product safety

III.

Manager

Design/manufacturing

interviews

class-Levelofperformanceofdesigners

Interview

-Invigorationofcommunication-Work environment
IV. Human error-Humanerror

On-sitePersonnel

prevention

class

Interviewinterviews-Status of obtaining
knowledge

about

products and manuals-Work environment
Meeting with host office

Review result confirmation

Meeting

Confirmation of schedule for second

officewith

hostday, etc.
Thursday,AM

Event observation

June 21

Review result confirmation
ConfirmationofmeetingOn-siteEvent observation(stretching, TBM)

Morning

meetingDocuments-Organization

Organization/management

policies/objectives

planning

IV. Human error-

implementation

II. Education/training

assurance

programsafety

aimed

at

and

method(passing

down

technical

knowledge)

improving morale-Human-Education/training-Implementation

culture-Activities

On-site(stretching, TBM)

I.

-Cultivatingforsecond day, etc.

Morning

Qualityschedule-Certification
error

III.

-Effective

Documents

prevention

Design/manufacturing

design/manufacturing
managementa.
Design/manufacturingorganizationb.
Design/manufacturing
manuals and abiding
by themc.
Design/manufacturing
management

IV. Human error

Manager class-Humanprevention

On-siteerror

On-siteIII.

-Effective

Design/manufacturing

manufacturing
managementb.
Design/manufacturing
manuals and abiding
by themc.

Equipment

maintenanced.

Manufacturing

planning/management

Interview

Manager classInterview- Grasping level of
performanceof

workers-Invigoration of worksite communication-Work environment
PM

I.

Personnel class

Organization/management-Safety

Interview
culturecultivation activities-Activities

aimed

at

error

[Fact confirmation]-Confirmation and coordination of review results with host-Creation of closing report

June 22AM[Fact confirmation]-Final coordination with host/final revision of closing report
Closing preparations (copying of documents, preparing venue)
Closing (explanation of results, closing address)

Design/manufacturing-Level of knowledge-Degreeprocedures

prevention

Friday,Worker classInterviewand experience

improving morale-Human

III.

to

which
are

followed-Work environment

6. Review method, Review Items, and Summarizing Review Results.
The following explains review method, review items and how review results weresummarized.
6.1 Review Method(1) Document review
Documents for each review item were explained, presented and then reviewed.
(2) Interviews
The Factory Director, who is the head of management, managers and generalemployees were interviewed under the theme of, “initiatives, etc.” Further, questions
were asked with respect to documents.
(3) Site Observation
Team reviewed The Factory activities by observing closely how The Factory
personnel conduct activities on site in conjunction with the result of document reviews
and interviews.
Furthermore, team proactively developed mutual communication with
NFT by providing beneficial information and examples like best practices inindustry during document reviews, interviews and observations.
6.2 Review Items
The review items are the three areas of “organization/management,”“education/training,” and “design/manufacturing” as well as “human error prevention.”
6.3 Summarizing Review Results
For each review item, document review, interviews and site
observations are conducted, and good practices and areas for improvement
are extracted.
Here, a “good practice” is a case “among activities to ensure safety at
the Factory that has implemented an appropriate, effective and uniquemethod, and that JANTI members wish to further convey to the nuclear
power industry and that is an excellent case study.

An “area for improvement” is “a matter that seen from theperspective of aiming to bring nuclear safety to the highest standard, a
proposal or the like that references best practices in the nuclear powerindustry for further improvements in activities to ensure safety at the
Factory.” Therefore, some cases, even if the current state of activities is at or
above general standards in the nuclear power industry, may be used as a
subject for an area for improvement.

7. Overview of Review Results
The Factory has learned the lesson of “the unraveling of safety culture” fromthe secondary piping rupture accident 1 and mislabeled piping problem 2 at Kansai
Electric Co., Inc. Mihama Unit 3.
Under the strong leadership of the Factory Director, managers and employees
are striving to assure safety and improve the quality of nuclear power products.
The Factory Director believes that a “reconstruction of the quality management
system (QMS)” is indispensable in the wake of the piping mislabeling problem and has
been developing “QMS reconstruction” activities since 2006. Through these activities a
QMS reconstruction system has been established, and various activities are underway.
However, the superintendent is aware that these activities have yet to permeate to the far
reaches of the organization and therefore devised the “QMS deepening” plan in 2007
and is strongly promoting the following as a way to permeate QMS through site
improvement activities.
In particular, (1) 2-day, 1-night leadership training for all section managers; (2)the implementation of face-to-face talks between the Factory Director and managers; (3)the implementation of compliance meetings as small group activities that include
subcontractor employees; and, (4) the use of check sheets in order to clearly identify
those items to be checked during patrols, is well under way.
However, since there are some activities that need improvement, such as safety
hazards prediction activities, and the basis for design technology standards, etc., itwould be good if the improvement activities currently underway were enhanced on-site
as well.
The following is an overview of the interview with the Factory Director and an
explanation of the 6 good practices and 3 areas for improvement that were extracted
from the results of this review. Note that these improvement items are notmatters for which immediate response is required from the perspective of
nuclear safety.
The following is a summary of the interview with the Factory Director(1) Issues that The Factory is facing
The Factory is engaged in “Quality Management System (QMS) deepening”
and “the pursuit of V21-07 strategies3.”
QMS is thought of as a management method and includes compliance,development ability enhancement, independence (the ability to think for yourself, createa plan and carry it out), and leadership enhancement. “V21-07 strategies” is an issue
that The Factory should execute during 2007.
(2) Monitoring the performance status of The Factory
The Superintendent’s office has a process map of 10 indices, such as “profit
and loss,” “productivity,” “VOC (voice of the customer),” etc., that are checked
periodically. Currently, each department is in the process of creating similar processmaps and there are approximately 80 such indices that are to be confirmed by everyone
above section manager level.
(3) What to expect in terms of processing when a mistake is madeFor mistakes that do not involve compliance, we believe that it is importantthat the individual not be blamed and that measures are taken to prevent reoccurrence.
However, there are times when individuals must be scolded and during these times it isimportant to scold them while conveying a sense of comradery.
(4) Expectations regarding the ability of managers to solve problems andself-assessments
The section managers of The Factory are like presidents of small and mid-sizedenterprises, and their expected performance is of the utmost importance to the
management of the site. Their leadership, technical knowledge and communication
skills are in question. Therefore, overnight leadership enhancement training for all
section managers (80 persons) was implemented five times last fiscal year.
There is a self-evaluation framework established within the QMS, and HSB(HSB Japan, Inc.) participates in the third-party assessment. However, there is still room
for improvement and we are aware that there are weaknesses. “QMS deepening” is an
issue for this fiscal year.

(5) Characteristics of, and situations involving, The Factory that the review team should
be aware of
The secondary piping rupture accident and mislabeled piping problem at
Kansai Electric Co., Inc. Mihama Unit 3 lead to a development of QMS activities. And,
we are leveraging this grueling experience to manage The Factory from a position thatputs importance on “quality” and aim to build a good and strong organization that canalways maintain excellent product quality.
7.1 Good Practices(Organization/management)-Strong leadership
The lessons of the secondary piping rupture accident and mislabeled piping
problem at Kansai Electric Co., Inc. Mihama Unit 3 have been learned, and the Factory
Director et al are showing their leadership and strongly promoting the improvement of
the Quality Management System (QMS), and the QMS framework4 is continuing topermeate. For example, interviews with managers confirmed that leadership training
and face-to-face meetings with the Factory Director and managers are effective.
-Compliance meetings
Approximately 4,000 employees (including site, part-time, and affiliatecompany personnel) partake in compliance meetings once every two months as part ofsmall group activities.
Themes discussed here are selected by the employees based on those issues
that are most likely to occur in the work place. For example, real-work situations, suchas, “what do you do when you discover an extremely minor discrepancy in designpressure,” are debated. Meeting results are reported to the department in charge, andthose examples that are discussed to be useful for other work sites are posted on andshared via a virtual bulletin board while implementation rate, follow-ups with thosepeople who do not understand, and the adequacy of theme selection are evaluated. Since
the meetings are small group activities, there is an atmosphere that makes it easy toconsult with people at the work site and voice concerns, all of which consequently leads
to improved adherence to rules.
(Education/training)-Improving the passing down of technical knowledge and comprehension in the Design
Department through the effective leveraging of e-learning
In the Design Department, there are efforts (e-drills) to leverage e-learning as
activities to improve quality. In these e-drills there are a lot of questions concerning
design basis and “know why,” and they aim to improve the passing down of technicalknowledge and comprehension by periodically forcing the drill-taker to solve problems.
Also, these drills are leveraged for educational guidance based on ascertaining thedegree of utilization.
(Design/manufacturing)-Effective leveraging of site patrols as a link in the chain of activities to prevent troubles
in advance in the Manufacturing Department
The nuclear power safety/quality improvement project working subcommittee
meets twice a month for the main purpose of implementing site patrols. At the meetings,
a check list that identifies particular items for the patrol to look for is drawn up, and a
Q&A sheet is used to interview members about past non-conformities, such as theMihama power station mislabeling problem. Furthermore, a pointed out item correction
recommendation is issued for those items pointed out during patrol and the items arefollowed up with. Through these improved, specialized patrols, non-conformity
information is laterally dispersed and non-conformities, such as mislabeling problems,
are prevented from being ignored.
(Human error prevention)-Utilization of a personalized daily calendar
In order to prevent human error, each group of the Manufacturing Department
personalized “daily quality diaries” and “daily safety diaries” are created in accordancewith the work that one is responsible for. These diaries are presented to the site and areread out loud in unison during the morning meetings before beginning work in an effort
to continue education. This daily diary is being leveraged effectively in regards toassuring quality and safety.
Reflecting past non-conformity information in procedures and confirming procedures
before beginning work
Quality information based on non-conformity information (combat lessons5),
and suitable information from past non-conformity records compiled by each section(know-why, non-conformity map, near-miss experience sheet, etc.) are reflected inManufacturing Department procedures that include work warnings, etc., and humanerror is being prevented by checking these procedures before beginning work. Past
non-conformity information is being leveraged effectively to prevent human error.
7.2 Area for improvements(Organization/Management)-Diagnosing work site safety culture (climate survey)
A safety culture policy has been enacted and it is being developed and activities
to improve it are being implemented. Confirmation of the results of cultivating
education concerning compliance, safety awareness and moral value is being done insome sections through tests and interviews, but it would be good to objectively ascertain
the status of safety culture at The Factory through questionnaires concerning work place
climate surveys and e-learning concerning safety culture.
(Design/Manufacturing)-Linking design technology standard basis and know why, etc.
The revision of technology standards is promoted and done with the help of
younger employees, but it would be good, for example, if during the revision, younger
employees were forced to make e-learning questions (e-drills) and link them withtechnology standards, thereby further improving basis and know why.
(Human Error Prevention)-Invigorating danger prediction activities
In the RKY activities after morning meetings, the leader was extracting andnoting dangerous elements, danger levels and countermeasures involved in the work on
the RKY (risk assessment/danger prevention) chart by him/herself. There are efforts toengage in effective RKY activities by thinking of the dangers that are present for each
person and discussing them as a group, however these efforts should be accelerated
since the activities have not been fully developed.

1(p6) On August 9, 2004, a secondary system pipe ruptured at Kansai Electric Co., Inc.
Mihama Unit 3 and high temperature secondary system cooling water spurted out
killing five workers and injuring six who were working in the turbine building.
2 (p6) During replacement of the aforementioned ruptured pipe, the labeling of theaforementioned piping was inappropriately corrected at Mitsubishi Heavy Industries
who had been charged with the manufacturing of it in February, 2005.

3(p7) Mitsubishi Heavy Industries’ management process includes mid/long-term plans
and short-term operation strategies, and strategies for surely and steadily implementing
these plans at The Factory are referred to as V21-07 strategies
4 (p8) This QMS framework is comprised of, “top-down quality policy given to
departments and sections aimed at developing quality objectives,” “bottom-up format inwhich small group activities that soak up on-site issues, and dept./section QMS
committee are improved,” “a management review that fuses these two things and serves
as a way to decide policy,” “work improvement conference, monitoring committees(internal audit) as support organizations” thereby constructing a QMS that is unique to
The Factory.
5 (p9) In the manufacturing department, non-conformity information is referred to as“combat experience.”