10-year Investigation Commission on the Fukushima Nuclear Accident:
Final Report by Investigation Commission on the Fukushima Nuclear Accident

Introduction:
Issues for the Second Independent Accident Investigation:
Do not brook the “normal pattern”
Kazuto Suzuki
An enormous earthquake of Magnitude 9.0 struck the Pacific Coast of Japan from the Tohoku region
to the Kanto region at 14:46 on March 11, 2011, causing a large tsunami. The huge amount ofseawater that rushed over the seawall into the premises of the Tokyo Electric Power Company’s
Fukushima Daiichi Nuclear Power Plant located in the coastal area of Fukushima flooded theunderground switchboard and emergency diesel generator. With the collapse of power towers, thetransmission line from outside was cut off, the power supply inside was also lost, and a so-called total
power outage (station blackout: SBO) took place. The Fukushima Daiichi Nuclear Power Plant lostits reactor cooling function, triggering a severe accident, which corresponded to an Article 15 eventin the Act on Special Measures Concerning Nuclear Emergency Preparedness (Nuclear Emergency
Act).
Not a single life was lost to direct radiation exposure in this unprecedented crisis thanks to the effortsof Director Masao Yoshida and others who struggled at the site of the Fukushima Daiichi Nuclear
Power Plant in danger of their own lives, the people supporting them, and perhaps luck. However,the number of earthquake related deaths in Fukushima Prefecture from the Great East Japan
Earthquake and evacuation accompanying the Fukushima Daiichi Nuclear Power Plant accident, was2,301 (as of March 2020) with a peak of 160,000 residents being forced to evacuate. The
consequences of the nuclear accident were extremely far-reaching with many of the evacuatedresidents forced into difficult circumstances, and as often reported, subjected to unfair bullying anddiscrimination in the places they evacuated to despite being victims themselves.
A report is not the end of matters
Regarding this accident, not only the Independent Investigation Commission on the Fukushima
Nuclear Accident, the predecessor of this research project, but many other investigatory bodies were
established, each examining the accident that took place at Fukushima Daiichi Nuclear Power Plant
from their own perspective and drawing their own lessons and proposals, including the Investigation
Committee on the Accident at the Fukushima Nuclear Power Stations (Government Accident
Investigation), the National Diet of Japan Fukushima Nuclear Accident Independent Investigation
Commission (NAIIC), the first of its kind in the history of constitutional government, theInvestigation Committee on the Nuclear Accident at the Fukushima Dai-ichi NPP by the Atomic
Energy Society of Japan (Academic Accident Investigation), and the TEPCO Accident Investigation
Committee established by TEPCO itself.
However, as is the case with many accident investigations, it is common in Japan for investigationsof such large-scale accidents to be disbanded once their findings are published. They are rarely
examined in terms of the extent to which the proposals and lessons are accepted by society, how theytransform governments and parties, and whether “preparedness” to prevent similar accidents fromhappening again has been put in place or not. As a result, when the shock in the immediate aftermathof the accident has not yet worn off, we take the recommendations and lessons of these reports
seriously, work on various reforms and changes to prevent the same thing from happening again,
putting new laws and systems in place. However, it is highly likely that the memories gradually fadeafter 10 years, that people forget why the accident happened, how they dealt with it and what lessons
they learned from it, and revert to the old habits and ways of thinking from before the accident. The
reports published by the accident investigation committees are stowed in a corner of the bookshelf5

10-year Investigation Commission on the Fukushima Nuclear Accident:
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never to be reopened, nor will we have the opportunity to check if the lessons and recommendations
have actually been realized.
The Fukushima Daiichi Nuclear Power Plant Accident was an accident of huge proportions thatshould not follow this “normal pattern”. First of all, not only are there many people who are still
unable to return to their hometowns with evacuation orders still in place, but those who for various
reasons are building new lives in the places they have evacuated to have also had their lives derailed
by the accident. The decommissioning work at the Fukushima Daiichi Nuclear Power Plant is still in
its infancy, and there are many places that cannot be accessed because the radiation dose is still high,and the overall picture of the accident remains unclear. In other words, the Fukushima Daiichi Nuclear
Power Plant accident is still an ongoing event, and the questions as to why the accident occurred, why
it was not possible to avoid it, and why it couldn’t be contained earlier are also still ongoing.
Secondly, despite the fact that the Fukushima Daiichi Nuclear Power Plant Accident has caused amajor swelling of the post-nuclear and anti-nuclear power movements and the pressure exerted bysuch social forces, the government has demonstrated its intention to maintain its strategy of using
nuclear power in its energy policy, and nine reactors have already been restarted (including the Ikata
Nuclear Power Plant Unit 3 that was suspended by the Hiroshima High Court, and Sendai Nuclear
Power Plant Unit 1 and 2 are suspended by noncompliance to the new safety regulations).
Additionally, six nuclear power plants have been approved by the Nuclear Regulation Authority as
conforming to its standards, and are likely to restart after coordination with local governments. If
nuclear power plants are to continue to operate in the wake of the Fukushima Daiichi nuclear accident,
the question is are the regulations permitting their operation appropriate? Have the operators running
the nuclear power plants learnt their lesson properly? How should people using the electricity that is
generated face the restart of nuclear power plants? In the process, we need to verify if the lessons
learned from the Fukushima Daiichi Nuclear Power Plant accident and the recommendations ofseveral accident investigation committees have been properly taken into consideration and arereflected in the regulation and operation of nuclear power plants, as well as “preparedness” should asimilar accident occur.
Thirdly, the Fukushima Daiichi Nuclear Power Plant accident had a major impact on post-war Japan's
economic growth and society, as well as the “shape of this country”. After World War II, we vowed
to be a peaceful nation under the new Japanese Constitution, and separating the development andutilization of science and technology from military purposes and focussing on economic development,
Japan enjoyed dramatic economic growth. Against such a backdrop, nuclear power was positioned
as a “dream energy” able to meet the rapidly growing demand for electricity, with an ultimate researchand development goal of creating a nuclear fuel cycle that made new nuclear fuel out of spent nuclear
fuel, something never realized in the world. However, the Fukushima Daiichi nuclear accident
fundamentally shook people’s faith in the “safety myth” that “nuclear power plants are safe” andbrought it painfully home to them that nuclear power plants were an energy source that carried therisk of causing a huge nuclear disaster. The economic development and civilized life we have enjoyedto date thanks to power sources are accompanied by these risks, and we need to consider how weshould solve questions such as how to deal with these risks and, if nuclear power generation
disappears, other problems that may instead arise such as, for example, the mass emission ofgreenhouse effect gas from burning fossil fuels to generate electricity.

Follow-up project to the Independent Accident Investigation
In order to break through this “normal pattern”," our research project reviewed the accident, postaccident changes and the lessons learned using the tenth anniversary of the Fukushima Daiichi

610-year Investigation Commission on the Fukushima Nuclear Accident:
Final Report by Investigation Commission on the Fukushima Nuclear Accident

Nuclear Power Plant accident as a catalyst. The goal was to analyze and study how much we havelearned, how far proposals have been put into practice, and if any given proposal has not been realized,
why it has not changed, or is not changing.
In the Independent Accident Investigation, the predecessor of this project, we examined many
phenomena based on the initial message from our Chairman Koichi Kitazawa to “understanding thebackground of this unfortunate accident and thereby learn the lessons to make our country safer.” InPart One, the history of the accident was organized chronologically and the cause of the accident was
analyzed from a technical point of view based on the public information available at the time. Since
the Independent Accident Investigation was unable to secure the cooperation of TEPCO, we wereunable to hear from TEPCO's executives and staff, including Director Yoshida who was in charge ofthe scene of the accident, but we expressed the view that, judging from the publicly available
information of the accident, the station blackout (SBO) had made it difficult to cool down the reactor,
resulting in a severe accident. Apart from the nuclear accident, we also explained the environmental
impact of the spread of radioactive material, the problem of internal exposure through food, and therisks posed by low-dose exposure as well as assessing the extent of the impact of the Fukushima
Daiichi accident and sharing a basic understanding of what was required for coping in the aftermathof the accident.
In Part Two, we focused on the response to the nuclear power plant accident, clarifying public
information about the process of response by the Kantei (the Prime Minister’s Official Residence)and the thoughts of each actor in their decision making through interviews with Prime Minister Naoto
Kan, the major cabinet members involved in decision-making, and executive officers who weregathered at the Kantei at the time. Significant problems existed here concerning the relationshipbetween the Kantei and the Nuclear and Industrial Safety Agency (NISA), as well as the mechanism
for information sharing between the government and TEPCO. Our analysis focused on the fact thatthe establishment of an integrated countermeasures headquarters for the government and TEPCO in
an extra-legal manner facilitated the flow of information and helped the government to organize theresponse. We also pointed out that decision-making in the Kantei was overly influenced by Kan's
individual play as well as the problems caused by micromanagement on the part of the Kantei (somemay have called it “Naoto Kan Risk” which means the management of accident by Prime Ministerwould increase risk of confusion), suggesting that the nuclear disaster manual at the Kantei bereviewed.
Furthermore in Part Two, we analyzed the government’s dissemination of information from theviewpoint of risk communication, examining the importance of such government information
dissemination at times of public unease as well as the performance of government spokesperson for
the Fukushima Daiichi Nuclear Power Plant accident, Chief Cabinet Secretary Yukio Edano, TEPCO,
and NISA. Additionally, the Independent Accident Investigation not only focussed on Japan, but also
analyzed how information was transmitted to the international community and how foreign countries
perceived and understood the accident. We also examined what is now referred to as “fake news” bylooking at misunderstandings about the risks, intentional hoaxes, and fear-based misconstructions
spread via SNS.
Additionally, the Independent Accident Investigation focuses on the response to nuclear disasters in
the field, and what role first responders, the Self-Defense Forces, the police, and the fire department
play, highlighting problems stemming from the absence of a premise of mutual cooperation, including
a lack of mutual communication and problems of command and the command system. In addition,
we discussed on SPEEDI, a mechanism for predicting the diffusion of radioactive materials ownedby the Ministry of Education, clarifying what SPEEDI could and could not do, concluding it could710-year Investigation Commission on the Fukushima Nuclear Accident:
Final Report by Investigation Commission on the Fukushima Nuclear Accident

not be used as a yardstick for ordering evacuations when the type and volume of emissions were
unknown. Furthermore, by investigating the government's evacuation instructions and the responseof local governments, we made it clear that the “safety myth” had created an absence of assumptions
about possible accidents and a lack of “preparedness”, which spurred confusion at the site and createdvarious problems.
Part Three analyzed the historical and structural factors that caused the Fukushima Daiichi Nuclear
Power Plant accident. First of all, we showed that acting as the ideological background for nuclear
safety, Design Basis Events (DBE) and deterministic safety evaluation lie at the root of safety
regulation, the underlying thinking here being that accident assumptions are blueprinted and a safety
design then drawn up based on that blueprint. We revealed that because the Fukushima Daiichi
Nuclear Power Plant accident far exceeded expectations, an “unexpected” response was required.
However, since it was not expected that such an “unexpected” event would occur, “preparedness” forthe accident went undone. Our proposal regarding this was to call for the introduction of the conceptsof probabilistic risk assessment and defense in depth, as well as accident management (AM)
responses.
Also in Part Three, the nature of nuclear safety regulation was historically examined from an
administrative stance, discussing the responsibilities of those involved in setting regulations and towhat extent tsunami, SBO, severe accidents, compound disasters and so on were envisioned andregulated for. We also analyzed the thinking of the regulatory authorities when designing said
regulations, raising the issue of Japan's distinctive safety regulation governance. We pointed out that
nuclear power business was not properly regulated and that this distinctiveness stemmed from theanomaly of introducing nuclear technology for peaceful use in Japan, an A-bomb victim, and abureaucratic dichotomy, on the other hand, of the Science and Technology Agency (MEXT) being incharge of research and development including the “nuclear fuel cycle”, and the then Ministry ofInternational Trade and Industry (current Ministry of Economy, Trade and Industry) regulating thecommercial operation of nuclear power plants; a dual system of policy decisions between the Nuclear
Power Commission and the Nuclear Safety Commission (NSC); a dual system of safety regulation
governance by NISA and the NSC; and pointed out the additional structural problem of a dual system
between the government pursuing its “national policy/private operation” and the electric powercompanies created rigid regulations and administrative ambiguity, which meant the power companies
were inadequately regulated.
In addition, we examined the ideological problems behind this kind of nuclear safety regulatory
governance, and in particular, how the so-called “safety myth” was created and maintained. Here, weclarified what kind of discourse was used in the nuclear power promoting community known as
the“nuclear village”, which is composed of stakeholders such as the government, academia,
businesses, manufacturers and the media. We also clarified how nuclear power plants were acceptedby local governments and how residents were persuaded. Furthermore, we discussed how anti-nuclear
power movements outside the central “nuclear power village” that promoted nuclear power
generation and the “nuclear power village” of local governments that accepted plants, were deployed
and often used litigation tactics, but that nuclear safety was switched into an issue of legal complianceby their resultant reliance on the judiciary, which placed decisions in the hands of judges who were
not nuclear experts.
In Part Four, we analyzed the global context, which was not a direct cause of the Fukushima Daiichi
Nuclear Power Plant accident, but is important in considering post-accident actions. We examinedthe distinctive nature of Japan's nuclear regulation in the context of international organizations suchas the IAEA and other countries, noting that Japan had long ignored experts in other countries when8

10-year Investigation Commission on the Fukushima Nuclear Accident:
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they pointed out issues of safety regulation. Furthermore, US-Japan relations played an importantpart in dealing with the nuclear accident, and as the United States took various measures from theperspective of protecting its own people, we looked at Japanese domestic responses to thecommunication gap between Japan and the United States and the measures taken by the United States,
highlighting issues involved in accepting international support.
Based on these discussions, the Independent Accident Investigation outlined the various “proximate,intermediate and remote causes” behind the Fukushima Daiichi Nuclear Power Plant accident,
concluding that fragmented optimizations in Japanese regulations created the loss of a global optimal
solution. We argued that what lay at the root of the Fukushima Daiichi nuclear accident was that
nuclear safety had lost what should be its ultimate goal of “continuous efforts to enhance safety” dueto the use of a design ideology of ignoring the “unexpected” based on design assumption events andthe absence of an idea of improving safety with the emphasis on hardware regulatory compliancestemming from judicial responses; the “safety myth” that was created by the interdependence ofcentral and local governments in the “nuclear power village”; and the response of a government and
Kantei unprepared for an “unexpected” event; all of which were partial optimizations and could not
be deemed to be an overall solution. Our message was that the lesson Japan should learn was toincrease its “resilience” towards crises. Crises such as natural disasters and the explosive spread of
infectious diseases always occur. We proposed engaging in crisis management by building
capabilities and systems to prepare for crises not only by government, but also businesses, first
responders, local governments, and the public, and improving leadership to anticipate a variety of“unexpected” events so that even if there was a crisis, we would be able to recover from it.
While upholding the spirit and problem awareness of our predecessor, the Independent Accident
Investigation, this second project will consider how society has changed, how the Japanese
government has changed, how TEPCO has changed, and how these lessons and recommendations
have been taken on board during the past ten years.

Subjects and themes to be examined
Based on the investigation analysis in the Independent Accident Investigation, this project deals withthe following themes and looks back over the past 10 years (project member in charge given inparentheses).
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Nuclear safety regulations (Akihide Kugo): NISA was dismantled as a “special agency” of the
Agency for Natural Resources and Energy, an external agency of the Ministry of Economy, Tradeand Industry, which has to date been responsible for safety regulations after the Fukushima
Daiichi nuclear accident, and merged into the Nuclear Regulatory Agency, an external agency of
the Ministry of the Environment, this being a “one-way ticket” and not an agency secondment. In
addition, the Nuclear Safety Commission whose task was to double-check nuclear safety wasabolished, and a highly independent Nuclear Regulatory Commission, a so-called Article 3
commission, was newly established. This new nuclear safety regulation mechanism is to establish
and implement safety regulations that are considered to be the “most stringent in the world”, but
it faces the challenge of whether it will be able to overcome the “safety myth” that was the causeof the Fukushima Daiichi nuclear accident. In this project, we will tackle issues regarding thenature of nuclear safety regulations, to what extent we have learned the lessons from the accident
in the past 10 years, and whether a new “safety culture” has been created.

-

TEPCO and its governance (Toshihiro Okuyama): TEPCO, the direct party involved in the
Fukushima Daiichi Nuclear Power Plant accident, had overwhelming political power under the910-year Investigation Commission on the Fukushima Nuclear Accident:
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regional monopoly and general cost method, and according to the Parliamentary Accident Report,
it was an entity capable of creating “Regulatory Capture” and influencing the regulatory
authorities. Under the “national policy/private operation” framework, it had an organizational
structure comparable to a huge bureaucratic organization, and due to the technical characteristicsof the nuclear sector, was characterized by an extremely closed and poorly ventilated corporate
culture. Did the Fukushima Daiichi Nuclear Power Station change the nature of TEPCO? The
Fukushima Nuclear Power Accident Summary and Nuclear Safety Reform Plan (commonly
known as the Anekawa Plan), which was announced as a reform plan for the nuclear power
division from inside TEPCO, advocated bold organizational reform and awareness reform, but
did such attempts change TEPCO? Deregulation of the power industry is creating a competitiveenvironment, but is it affecting TEPCO's corporate culture? Furthermore, will TEPCO, which
ultimately bears the costs involved in dealing with the Fukushima Daiichi Nuclear Power Plant
accident and compensation, evolve into a company that can withstand the payment?
-

Risk Communication (Naoya Sekiya): In a nuclear accident, fear of damage from invisible
radiation dominates people's minds. Everyone is concerned about how much risk an accident willcause and how much their life will be threatened. In the Fukushima Daiichi Nuclear Power Plant
accident, Chief Cabinet Secretary Edano fronted the government and disseminated government
information, but in the confusion at the time of the disaster, while his message “There is no
immediate effect” was accurate, it failed to eradicate people’s anxiety. The communication of
information from TEPCO and NISA also attracted attention to the question of wording such as“core fusion”, which fanned people's anxiety and distrust. Social networks (SNS) have developedin the field of risk communication in the last 10 years, and communication methods have changed
significantly from those of 2011. In addition, the question of rumors experienced when the
Fukushima Daiichi Nuclear Power Plant accident was yet to be under control is still an ongoingone. We will discuss the desirable nature of risk communication in these circumstances of modern
times, and how the lessons learned from the Fukushima Daiichi Nuclear Power Plant Accident
are being utilized for information dissemination by the government and TEPCO.

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Crisis management in the Kantei (Yasuaki Chijiwa): It is safe to say that the most well read partof the report was the section on crisis management at the Kantei, the core theme of the
Independent Accident Investigation. Crisis management at the Kantei has been institutionallystrengthened by the reorganization of the then Security and Crisis Management Office into the
Situation Response and Crisis Management Office as well as by the addition of the National
Security Secretariat (NSS). However, it is necessary to re-examine the human resources who drive
the system, and to what extent the top management and executives who should assume leadershipin crisis management are fully aware of “preparedness”. At the time of the Fukushima Daiichi
Nuclear Power Plant accident, it was a Democratic Party government, and it is now an LDP
administration and a long-term one at that, so there are circumstantial differences including theexperience gained in crisis management during various natural disasters and an improved ability
to respond to situations. However, after excluding the peculiarities of such individualadministrations, we will examine whether it is capable as a framework for and a system of crisis
management when a nuclear disaster occurs - often involving crisis management in a complex
crisis.

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Logistics (Yuki Kobayashi): It is no exaggeration to say that logistics make or break dealing witha situation in a nuclear disaster. The Fukushima Daiichi Nuclear Power Plant accident lacked
physical “preparedness” for a nuclear disaster, and it is undeniable that the accident would havebeen much worse without physical equipment securing power on site, pump cars for water supply,
and the high-pressure concrete pump car called the Giraffe that was miraculously effective in10

10-year Investigation Commission on the Fukushima Nuclear Accident:
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cooling spent fuel pools. Such logistical aspects have been emphasized even in post-accident
nuclear safety regulations, and thorough physical “preparedness” for power supply vehicles andfire engines is now a requirement for restarting nuclear power plants. Are these regulations
appropriate after all? Will these logistics work properly in the event of a compound disaster?
Furthermore, even if such hardware is in place, how well can it be operated? Have the lessons
from the accident perhaps led to excessive “preparedness”? If only because of their visibility,
physical logistics give a sense of security, but it is meaningless if they become merely a decoration
to provide that sense of security. Here we will also discuss the pros and cons of a “Japaneseversion of FEMA” that was debated following the accident.
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First Responders (Koichi Isobe): A theme that was dealt with in the Independent Accident Reportbut hardly examined in other accident reports is the role of first responders such as the SelfDefense Forces, police, and fire fighters. Although the SDF, police, and fire fighters are notnecessarily primary responders in a nuclear disaster, the sight of the Ground Self-Defense
helicopter dropping seawater into Unit 3's spent fuel pool at the Fukushima Daiichi Nuclear Power
Plant accident was widely reported, and regardless of its impact, the fact that the Self-Defense
Forces were responding to a nuclear disaster provided people with a sense of security and courage
to the parties actually dealing with the accident. The fire department also played an important rolein injecting water into the reactor, and the police played a role in maintaining social order invarious situations, including the evacuation of residents. However, the issue was that noassumption was made as to what role these first responders would play in a nuclear disaster, andthere was no way of dealing with it, either institutionally or in terms of mission. In addition, whenthese organizations, which normally have separate tasks, cooperate and deal with a single
operation, a heavy load is placed on communication and coordination between the organizations.
What lessons have been learned from the various problems experienced in the Fukushima Daiichi
Nuclear Power Plant accident, and what kind of actions are now being taken? Further, when anuclear disaster is in an extreme state, it is excessively difficult for a private business operator toorder its employees to risk their lives to deal with the accident. At such a time, is it then up to
SDF officers, who pledge to “to face events without regard to risk, to strive to the utmost of myabilities to complete the assigned tasks”?

-

Rebuilding (Hiroshi Kainuma): An issue not touched upon in the Independent Accident
Investigation was the question of rebuilding. In the Fukushima Daiichi accident, the evacuation
area expanded from 5km to 10km then 20km, and 160,000 people were forced to evacuate theirhomes. Ten years later, the places where the evacuation order has been lifted have expanded, butthere are still some places designated as evacuation areas. Additionally, people who haveevacuated cannot immediately return to their homes, and the rebuilding of entire cities andinfrastructure for daily life are major issues. What should we do about long-term rebuilding aspart of the problem of a nuclear accident? Although it is hard to provide a clear answer to this
topic, “preparedness” for a nuclear accident should also encompass “preparedness” for theevacuation of people and rebuilding. Although nuclear safety regulations now require thesubmission of resident evacuation plans, it is hard to say they are fully prepared for rebuilding. It
will be the mission of this project to provide some direction in discussing this issue as well.

Investigatory goals
This concludes the summary and recommendations of the report on the Private Accident report.
However, the investigatory goals of this project are not limited to the proposals of Independent
Accident Investigation. The Government Accident Report, the Parliamentary Accident Report, and
the Academic Accident Report also make meaningful recommendations, which we have included inour deliberations. It is not, however, the intention of this project to cover all of the lessons and1110-year Investigation Commission on the Fukushima Nuclear Accident:
Final Report by Investigation Commission on the Fukushima Nuclear Accident

recommendations dealt with by these accident investigations, or to verify and re-verify them one byone. In this report, we will continue to examine the main themes to be investigated, such as nuclear
safety regulations and TEPCO's governance, based on the recommendations presented by past
accident reports.
To close, I have posted the reference material that summarizes the recommendations presented byeach accident report according to this project’s research topics.

Reference Material
Proposals from the Private, Government, Parliamentary and Academic Accident Investigations
The proposals announced by the Private, Government, Parliamentary and Atomic Energy Society ofJapan Accident Investigations have been organized into themes for each chapter, the issues to be
examined in each chapter also being listed. Even those issues not explicitly proposed as“recommendations” but hinted at in any of the accident reports are included.
Chapter 1 Safety Regulations
・Accident management (AM) regulatory requirements and institutional considerations (Independent
Investigation Commission on the Fukushima Daiichi Nuclear Accident, 2012, p.266).
・Establishment of an effective nuclear safety regulatory body independent of the administration
promoting nuclear power (Independent Investigation Commission on the Fukushima Daiichi
Nuclear Accident, 2012, p.388).
・Overcoming the 2-3 year transfer problem: Developing professional human resources whose life
work is safety regulation (Independent Investigation Commission on the Fukushima Daiichi
Nuclear Accident, 2012, p.388).
・Formation of a Critical Expert Group on safety regulation governance (Independent Investigation
Commission on the Fukushima Daiichi Nuclear Accident, 2012, p.321).
・ Revision of assumptions in nuclear disaster countermeasure manuals, etc. (Independent
Investigation Commission on the Fukushima Daiichi Nuclear Accident, 2012, p.100).
・Parliamentary monitoring of regulatory authorities (The National Diet of Japan Fukushima Nuclear
Accident Independent Investigation Commission, 2012, p.2).
・Requirements for a new regulatory body (The National Diet of Japan Fukushima Nuclear Accident
Independent Investigation Commission, 2012, p.3)
・ Review of nuclear regulations (The National Diet of Japan Fukushima Nuclear Accident
Independent Investigation Commission, 2012, p.6)
・Countermeasure proposals with a view to compound disasters (Cabinet Office, Government ofJapan, 2012, p.433).
・Proposal for a switch in risk awareness (Cabinet Office, Government of Japan, 2012, p.433).
・Recommendations regarding the construction of accident prevention measures (Cabinet Office,
Government of Japan, 2012, p.434).
・Proposal regarding the need for comprehensive risk assessment (Cabinet Office, Government ofJapan, 2012, Report p.435).
・Proposals for severe accident countermeasures (Cabinet Office, Government of Japan, 2012,
p.435).
・Recommendations for better monitoring operations (Cabinet Office, Government of Japan, 2012,
p.436).
・Proposals for meeting international standards including the IAEA (Cabinet Office, Government of12

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Japan, 2012, p.439).
・Proposal regarding the ideal state of a nuclear safety regulatory body (Cabinet Office, Governmentof Japan, 2012, pp.439–441).
・Recommendations for rebuilding a safety culture (Cabinet Office, Government of Japan, 2012,
p.441).
・Setting quantitative safety goals and efforts for social sharing and dialogue (Atomic Energy Societyof Japan, 2014, p.358).
・ Establishment of basic, systematic safety principles that go beyond individual technicaldevelopment (Atomic Energy Society of Japan, 2014, p.359).
・Development of a “regulatory book” of ideas for defense in depth/Strengthening measures against
external events/Strengthening measures from past accidents (Atomic Energy Society of Japan,
2014, pp.360–362).
・The approach of safety regulatory agencies (Atomic Energy Society of Japan, 2014, p.367).
Chapter 2 TEPCO and Its Governance・ Lack of an appropriate relationship between regulators and operators: the need for mutual
understanding and respect between the two parties (Independent Investigation Commission on the
Fukushima Daiichi Nuclear Accident, 2012, pp.289–290).
・Ambiguities of responsibility brought about by "privately administered national policy”/ Business
responsibility for reviewing safety regulation governance (Independent Investigation Commission
on the Fukushima Daiichi Nuclear Accident, 2012, pp.320–321).
・The limits of responsibility of the operators of privately administered policy–The irreplaceable roleof the state (Independent Investigation Commission on the Fukushima Daiichi Nuclear Accident,
2012, p.388).
・Monitoring electric power companies (The National Diet of Japan Fukushima Nuclear Accident
Independent Investigation Commission, 2012, pp.2–3).
・ Proposals regarding the nature of TEPCO (Cabinet Office, Government of Japan, 2012, p.441).
Chapter 3 Risk Communication
・ Consensus building in the ambiguity of scientific knowledge ・ Cross-border scientificcommunication (Independent Investigation Commission on the Fukushima Daiichi Nuclear
Accident, 2012, p.66).
・ Social media and risk communication during a nuclear crisis (Independent Investigation
Commission on the Fukushima Daiichi Nuclear Accident, 2012, p.145).
・ Recommendations regarding public relations and risk communication (Cabinet Office,
Government of Japan, 2012, p.436).
・ Proposal for incorporating new knowledge into disaster prevention plans (Cabinet Office,
Government of Japan, 2012, p.434).
・ Recommendations on how to evacuate residents (Cabinet Office, Government of Japan, 2012,
pp.437–438).
・ Recommendations regarding public understanding of radiation (Cabinet Office, Government ofJapan, 2012, p.438).
Chapter 4 Crisis management in the Prime Minister’s Office・Lessons related to micro management in the Prime Minister’s Office in dealing with the nuclear
accident (Independent Investigation Commission on the Fukushima Daiichi Nuclear Accident,
2012, p.98).
・Lessons on various issues in the crisis management of complex disasters by the Prime Minister’s

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Office (Independent Investigation Commission on the Fukushima Daiichi Nuclear Accident, 2012,p.119).
・Institutional understanding of Prime Minister’s Office staff capable of responding to nuclear
disasters/education, training and systems that support advice to politicians (Independent
Investigation Commission on the Fukushima Daiichi Nuclear Accident, 2012, p.101).
・Review of the government's crisis management system (The National Diet of Japan Fukushima
Nuclear Accident Independent Investigation Commission, 2012, p.2).
・Proposal for rebuilding crisis management systems in the event of a disaster (Cabinet Office,
Government of Japan, 2012, p.435).
・Proposal regarding the nature of the Nuclear Emergency Response Headquarters (Cabinet Office,
Government of Japan, 2012, pp.435–436).
Chapter 5 The Logistics of Responding to a Nuclear Emergency
・Recommendations for various reviews of the off-site center system (Independent Investigation
Commission on the Fukushima Daiichi Nuclear Accident, 2012, pp.168–169).
・ Necessity of a FEMA-like nuclear disaster response unit as the last stand (Independent
Investigation Commission on the Fukushima Daiichi Nuclear Accident, 2012, p.388).
・Proposals for an off-site center (Cabinet Office, Government of Japan, p.436).
・Emergency preparedness and strengthening response measures (Atomic Energy Society of Japan,
2014, p.363).
Chapter 6 First Responders
・Lessons and recommendations regarding each first responder’s command system in the event of alarge-scale disaster (Independent Investigation Commission on the Fukushima Daiichi Nuclear
Accident, 2012, p.168).
・ Issues concerning the on-site response of first responders in the event of a nuclear disaster(Independent Investigation Commission on the Fukushima Daiichi Nuclear Accident, 2012, p.168).
・Necessity of a FEMA-like nuclear disaster response unit organization as the last stand (Independent
Investigation Commission on the Fukushima Daiichi Nuclear Accident, 2012, p.388).
・Suggestion for a whole-of-alliance approach in coordinating allies during crisis management(Independent Investigation Commission on the Fukushima Daiichi Nuclear Accident, 2012, p.380).
・Maintenance of a common base for cooperation between first responders (Atomic Energy Societyof Japan, 2014, p.363).
Chapter 7 Rebuilding
・Necessity of follow-up survey for monitoring and managing the effects of radiation exposure on
residents in the medium to long term (Independent Investigation Commission on the Fukushima
Daiichi Nuclear Accident, 2012, p.67).
・Government response to disaster victims (The National Diet of Japan Fukushima Nuclear Accident
Independent Investigation Commission, 2012, p.2).
・Proposal for SPEEDI system (Academic Accident Report p.363)
・Radiation monitoring and long-term dose evaluation (Atomic Energy Society of Japan, 2014,
p.370).
・Legal regulations and guidelines for decontamination (Atomic Energy Society of Japan, 2014,
p.370).
・Setting a decontamination target area (Atomic Energy Society of Japan, 2014, p.370).
・Decontamination and decontamination technology (Atomic Energy Society of Japan, 2014, p.370).

14

10-year Investigation Commission on the Fukushima Nuclear Accident:
Final Report by Investigation Commission on the Fukushima Nuclear Accident

References
Atomic Energy Society of Japan. (2014). Fukushima Daiichi genshiryoku hatsudensho jiko ni
kansuru chôsa înkai [Final Report on the Accident at Fukushima Daiichi Nuclear Power
Plant]. Report, March 26. Tokyo: AESJ. (In Japanese.)
Cabinet Office, Government of Japan. (2012). Seifu jiko chô saishû hôkokusho [Final Report ofInvestigation Committee on the Accident at Fukushima Nuclear Power Stations of Tokyo
Electric Power Company]. Report, June 23. Tokyo: Cabinet. (In Japanese.)
Independent Investigation Commission on the Fukushima Daiichi Nuclear Accident. (2012).
Fukushima gennpatsu jiko dokuritsu kenshô înkai: chôsa, kenshô hôkoku sho [Independent
Investigation Commission on the Fukushima Daiichi Nuclear Accident: Report on theInquiry and Investigation]. Tokyo: Rebuild Japan Initiative Foundation. (In Japanese.)
The National Diet of Japan Fukushima Nuclear Accident Independent Investigation Commission.
(2012). Tōkyō denryoku fukushima genshiryoku hatsudensho jiko chōsa iin kaihōkokusho[The official report of the Fukushima Nuclear Accident Independent Investigation
Commission] (Digest version). Report. Tokyo: Diet. (In Japanese.)15