STATUS OF FUKUSHIMA INCIDENT RESPONSE CORRECTIVE ACTIONS 

After Action 

Report 

Category 

After Action Report Observation Action 

2.1.1 Role and 

Mission 

The U.S. Nuclear Regulatory 

Commission’s (NRC’s) response role in an 

international event is not well defined, and 

the agency's mission of ensuring adequate 

protection of public health and safety to 

U.S. citizens abroad was not well 

communicated to the staff throughout the 

event. 

- (Complete) The NRC has participated in a 

White House-led working group that produced 

an international response protocol document 

outlining Federal agency roles and 

responsibilities during response to an 

international event. 

- (Ongoing) Incorporate new international 

protocol requirements into existing 

procedures, processes, and training. 

2.1.2 Federal 

Coordination in 

an International 

Response 

The NRC lacks formal guidance for 

integrating into the overall Federal 

response to an international nuclear 

incident. 

- See 2.1.1. 

- (Complete) A Federal Coordination Team 

(FCT) has been created and incorporated into 

the response program to manage the NRC 

and Federal interface during both domestic 

and international events. 

2.2.1 Task 

Management 

The absence of a formal task management 

process led to difficulty in tracking and 

prioritizing tasks. The existing informal 

process also lacks a means for assigning 

tasks to the various NRC line 

organizations. 

- (Ongoing) Integrate external tasking from 

response into normal office processes (e.g., 

the Office of the Executive Director for 

Operations (OEDO) ticket system). 

- (Ongoing) Proposed Executive Team (ET) 

reorganization will provide more direct OEDO 

oversight of response operations, including 

the organizational capability to direct and 

track agency tasking within and outside of the 

response effort. 

2.2.1 Task 

Management 

The WebEOC® Task Tracker was 

beneficial for capturing assigned mission 

tasks, but the limited usability of the 

software resulted in ineffective use of the 

tool. 

- (Complete) Updated WebEOC® software. 

- (Complete) Created board user guide. 

- (Ongoing) Task tracking protocol will be 

created as part of Incident Response Manual 

Chapter (IRMC) improvements. 
2.2.2 Leadership 

Continuity 

The response structure does not establish 

long-term command and control or 

continuity of leadership. 

- (Ongoing) Proposed ET reorganization will 

change structure to improve leadership 

continuity, command and control, and to 

better align with real-world roles and 

responsibilities. 

- (Complete) Conducted tabletop exercise of 

proposed ET reorganization. 

- (Ongoing) Determine viability of proposed 

structure in full response exercises. 

2.2.3 Shift 

Turnover and 

Continuity 

Individual response team directors did not 

consistently conduct turnover briefings, 

which complicated shift continuity and task 

completion. 

- (Complete) Made improvements to 

WebEOC® that have simplified and quickened 

shift turnover. 

- (Ongoing) Proposed ET reorganization will 

improve senior-level continuity. 

- (Ongoing) IRMC upgrades propose 12-hour 

versus 8-hour shifts (minimizing turnovers). 

2.2.4 Protracted 

and Multiunit 

Events 

The NRC Incident Response (IR) Program 

does not train or exercise responders for 

protracted or multiunit events. 

- (Complete) The series of functional 

exercises used to certify the new Three White 

Flint North (3WFN) Headquarters Operations 

Center (HOC), in which all responders 

participated, made use of multiple event 

scenarios. 

- (Ongoing) An upcoming fiscal year (FY) 15 

exercise will potentially use a multiple event 

scenario. 

- (Ongoing) An upcoming FY 15 exercise will 

require a response of significantly longer 

duration than that seen in historical exercises. 

- (Ongoing) In-progress IRMC upgrades will 

integrate and update multiple event and 

protracted response guidance. 
2.2.5 Expertise 

and Training 

The HOC used trained volunteer 

responders to fill team positions. As the 

response period lengthened, it became 

necessary to use untrained volunteers to 

supplement the response teams. 

Untrained responders lacked the 

necessary response training and 

knowledge of HOC operations, while 

trained responders indicated a need for 

more drills with an increased focus on 

HOC procedures and tools. 

- (Complete) Conducted concerted recruiting 

efforts since the Fukushima response to 

deepen the available pool of trained and 

qualified responders. 

- (Complete) Developed just-in-time training 

programs for general response and for key 

positions to provide rapid training to new 

responders should they become necessary 

during response. 

- See 2.2.3 for shift length and turnover 

improvements. 

- (Complete) Updated the IR program 

processes and structure for watchstander 

scheduling and watchbill generation to make 

better use of qualified responders. 

- (Ongoing) Meet with Office of the Chief 

Human Capital Officer (OCHCO) and National 

Treasury Employees Union (NTEU) to explore 

the benefit of modifying responder position 

descriptions to reflect their duties or revisit the 

nature of staffing the IR teams. 

2.2.6 Roster of 

Subject Matter 

Experts 

Subject matter experts (SMEs) were a 

valuable resource throughout the 

response, not only supporting internal 

objectives, but also supporting other 

Federal stakeholders. However, during the 

response, responders were not readily able 

to access an agency-wide SME database. 

- (Complete) Expanded pre-existing 

IR program-internal lists of SMEs since the 

Fukushima response. These are periodically 

updated. 

- (Future) Work with OCHCO to determine 

the most effective way to find SMEs outside 

of the IR program. 

2.2.7 Conflicts 

with Regular 

Duties 

Many responders who volunteered for 

response duty were also expected by their 

supervisors to continue their normal work 

duties. Response team leaders had no 

direct control over the voluntary 

responders’ schedules or the duration of 

their service. 

- (Ongoing) Proposed ET reorganization to 

provide more direct OEDO oversight of 

response operations, including the 

organizational authority, procedures, and 

processes to direct agency resources toward 

the response effort. 

- (Ongoing) This observation may also be 

partially addressed by the OCHCO/NTEU 

outreach effort in 2.2.5. 
2.2.8 Team 

Management/ 

Team Mission 

The NRC’s lack of international response 

experience, coupled with limited team 

cross-training, caused uncertainties and 

confusion among responders regarding 

their team-specific mission assignments 

and the roles of other teams. 

- (Complete) Team training and guidance 

about team functions have been provided to 

responder references. 

- (Ongoing) Addressed in 2.1.1 and 2.2.2. 

2.2.9 

International 

Response 

Considerations 

The NRC IR program lacks a 

comprehensive international structure. 

- This observation relates to a lack of 

corporate support for the NRC personnel who 

traveled to, and responded from, Japan 

during the event. 

- (Complete) The NRC established a 

response coordination group and wrote 

procedures to handle logistics and planning 

aspects of the NRC response, including 

support to deployed headquarters (HQ) 

personnel. This group, in part, will handle 

deployment, whether domestic or 

international, of HQ and/or regional 

personnel. 

2.3.1 Records Response teams had an insufficient 

protocol for recordkeeping, leading to 

inefficient information management. This 

caused duplicative efforts, limited capture 

of lessons-learned documentation, and 

inefficient management of requests for 

information. 

- (Complete) The NRC established a records 

management group as part of response 

coordination. This group is responsible for 

managing electronic files during response and 

transfer of information during potential 

Freedom of Information Act (FOIA) requests. 

 - (Complete) Intentionally designed the 

3WFN HOC to focus on electronic medium, 

resulting in fewer hard copies. 

2.3.2 FOIA 

Requests 

During the response, the NRC received a 

large number of FOIA requests. This 

caused already limited resources to be 

re-directed to mandatory FOIA work rather 

than IR activities. 

- (Complete) See 2.3.1. 

2.3.3 Reports 

and Procedures 

Most response procedures and protocols 

are not adequate for protracted, multiunit or 

international events. Additionally, no 

process currently exists to formalize HOC 

protocols throughout the response. 

- (Complete) Staff has performed a 

program-wide review of response procedures 

and has initiated a comprehensive restructure 

and upgrade. 

- (Ongoing) As part of the procedure upgrade 

(IRMC-100), the process for generating and 

approving new procedures has been 

streamlined and moved to lower operational 

levels, where appropriate. 
2.4.1 Staffing 

and 

Scheduling 

The voluntary nature of the current 

response program presented many 

challenges in supplying fully qualified 

responders to staff the HOC for the 

duration of the response. 

- (Complete) The NRC has improved 

scheduling tools and process and developed 

guidance for longer shifts. 

 - (Ongoing) Responder commitments are 

being addressed in 2.2.5. 

2.4.2 Human 

Limitations and 

Human Capital 

The limited size of the qualified responder 

pool, coupled with the length and 

complexity of the event, led to fatigue and 

stress issues. 

- (Ongoing) See 2.2.5. 

2.4.3 Equipment The Japan team dispatched from HQ had 

difficulty securing the necessary 

emergency response equipment since 

most equipment is provided for 

region-based site teams. Regional offices 

had concerns about replacement and 

reimbursement of equipment used during 

the response. 

- (Complete) See 2.2.9. 

2.4.4 Facilities The responders identified many operational 

improvements during the response that 

should enhance the HOC facility. 

- (Complete) Included all design elements in 

buildout of 3WFN HOC. 

2.4.5 Security The Japan team established and 

maintained communications with the HOC; 

however, secure communications 

capabilities were limited because of the 

unavailability of secure equipment on site 

and requisite information access of 

ET members. 

- (Complete) Included improved secure 

communications elements in the buildout of 

3WFN HOC. 

2.5.1 Internal 

Communications 

Responders identified several challenges 

with interteam communications. 

- (Complete) Incorporated recommendations 

into team trainings and practiced during 

exercises, including the following: 

- creation of HOC-wide phone directory 

and conference bridge directory. 

- training and procedure upgrades to 

incorporate regular team briefings. 

- incorporation of a common priorities 

board in WebEOC®. 

- incorporation of an event summary 

board in WebEOC® to communicate 

event milestones. 
2.5.2 

Interagency 

Communications 

Formal protocols and interagency 

agreements related to roles of external 

liaisons in the HOC during an international 

response did not exist. 

- (Complete) Established the FCT, which 

provides: 

- team-level expertise on roles, 

responsibilities, and information sharing 

with other Federal agencies and 

stakeholders. 

- NRC liaisons to external agencies. 

 - processes for intake, management, 

and support of external agency liaisons 

responding at the NRC HOC. 

2.5.2 

Interagency 

Communications 

Daily conference calls with international 

and industry partners greatly enhanced 

overall communication and mission 

priorities. 

- (Complete) Industry developed a 

coordinated, consistent approach to response 

efforts by issuing FLEX response guidelines, 

establishing FLEX-focused infrastructure 

(such as the national response centers) and 

developing mission support priorities with 

Federal, State, and local agencies. 

- (Complete) The Reactor Safety Team has 

trained on the FLEX program and has 

generated a process to incorporate it into the 

larger response effort. 

2.5.3 Public 

Communications 

The use of scientific figures and numbers 

in public messaging by the NRC created 

confusion with the public. 

- (Ongoing) A Public Information Desk is 

being created to appropriately convey 

important information to the public. 

2.5.3 Public 

Communications 

The influx of the calls from the concerned 

public to the HQ Operations Officer and the 

regional offices created a significant 

distraction to the response. 

- (Ongoing) The Public Information Desk, 

discussed above, will alleviate call volume 

from regional offices. 

2.5.4 

State/Regional 

Communications 

The international nature of the event 

challenged communication efforts with 

State and regional stakeholders. 

- (Complete) Modified internal processes and 

Liaison Team procedures to specifically 

address provision of information to State and 

regional stakeholders. 

2.5.5 Technical 

Communications 

Technical communication was not 

consistent and was often confusing. 

- (Complete) Discussed this observation, 

related to the mixed use of metric and English 

units, in detail and determined it to be a reality 

of international response. 

- (Complete) Responder training has already 

been improved to stress importance of 

consistent messaging. 
2.6.1 RASCAL RASCAL does not support creation of a 

single impact plot from multiple source 

terms, provide impact perspective at 

distances greater than 50 miles (80 

kilometers), and only has a maximum 

calculation period (release duration) of 

48 hours. 

- (Complete) RASCAL 4.3 was released in 

2013 and incorporated all identified 

recommendations from Fukushima. 

2.6.2 WebEOC® The full functionality and capabilities of 

WebEOC® were not used during the 

response. 

- (Complete) Improvements to WebEOC® are 

an ongoing initiative. The NRC used all 

feedback from the Fukushima response to 

improve boards. 

- (Complete) Provided training on 

improvements and created user guides to 

supplement training. 

2.6.3 General 

Technology 

Issues 

Laptops and computers: Some laptops 

had issues with software updates and 

connectivity to printers and other systems 

that had to be resolved. Also, the 

computers at the ET table allowed 

connectivity and productivity throughout the 

day, but required additional setup and 

training for use. 

- (Complete) Addressed computer issues in 

the buildout of 3WFN HOC. 

2.6.3 General 

Technology 

Issues 

Agencywide Documents Access and 

Management System (ADAMS) software 

was not installed on all HOC workstations, 

which made it difficult for responders to 

access and print agency documents 

needed throughout the response. 

- (Complete) Made ADAMS accessible in 

3WFN HOC. 

2.6.3 General 

Technology 

Issues 

Credentials: Volunteers without prior HOC 

experience required login credentials when 

reporting for their initial shifts. Technical 

support staff members were very 

responsive in establishing accounts for the 

responders, but this created a distraction 

from other duties. Experienced responders 

noted that there were no desktop reference 

guides to assist in accessing the systems. 

- (Complete) Created desktop reference 

guides to provide references for new 

responders. 

2.6.3 General 

Technology 

Issues 

Workstations: Many responders noted that 

computer monitors were too small to allow 

viewing of certain documents, and other 

responders indicated they would prefer two 

monitors at their workstations. 

- (Complete) Improved workstations during 

the 3WFN HOC buildout. 
2.6.3 General 

Technology 

Issues 

Recorded Lines: The phones with 

recorded lines caused confusion in the 

HOC. There was no clearly defined policy 

or practice for use of recorded phone lines. 

- (Complete) Limited recorded phone lines to 

only four pre-established external bridges. 

- (Complete) Provided phone directories to all 

response workstations. 

2.6.3 General 

Technology 

Issues 

E-mail Accounts: Complications with the email system — including size limits for 

attachments, HOC account names, and 

difficulty locating and retrieving previous 

communications, contributed to confusion 

and miscommunications. Responders 

regularly monitored the HOC e-mail 

accounts, but the HOC e-mail addresses 

only indicated computer station 

identification and did not indicate names or 

job titles of individuals. As a result, 

responders unknowingly sent e-mails to 

incorrect recipients. 

- (Complete) Standardized HOC e-mail 

addresses. 

- (Complete) Provided an e-mail list to all 

response workstations.