The 6th International Symposium and Seminar
on Global Nuclear Human Resource Development
for Safety, Security and Safeguards,
Tokyo Institute of Technology, Tokyo, Japan
February 20, 2017
Toyoshi Fuketa
Nuclear Regulation Authority
Lessons Learned
from the Fukushima Dai-ichi Accident
regarding Safety Culture of Regulatory Body1In lieu of Introduction
XII. Lessons Learned From the Accident Thus Far
(28) Thoroughly foster safety culture
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 the
public, should take a hard look at whether they have been serious in
addressing new knowledge in a responsive and prompt manner, not
leaving any doubts in terms of safety. Agility
... Japan will establish a safety culture .., namely that pursuing
defenses-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.
Report of Japanese Government
to IAEA Ministerial Conference on
Nuclear Safety, June 20112Diet 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 of
governance by said parties. They effectively betrayed the nation’s right to
be 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 a
safety myth that existed among nuclear operators including TEPCO as
well 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 at
Fukushima Nuclear Power Stations of Tokyo Electric Power Company, July 23, 20123Message from NAIIC Chairman
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 the
ingrained conventions of Japanese culture:
Cultural Bias
our reflexive obedience;
our reluctance to question authority;
our devotion to ‘sticking with the
program’;
our groupism; and
our insularity.
Look universal May produce another safety myth
National Diet’s Report4Safety myth prevailed
Complacency
Bureaucracy
Lack of agility
Cognitive bias
Continuous improvement ceased
Collapse
Isolation
Missed the chances
Sending later
Lack of independence
"Complacency" together with "Bureaucracy" allow "Safety
myth" to prevail, letting "Continuous improvement" cease.
Institutional failures5Cognitive Bias
We tend to have positive illusions that lead us to
conclude that a problem doesn’t exist or is not severe
enough to merit action.
We overly discount the future, reducing our courage to
act now to prevent some disaster that we believe to be
quite 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., "Predictable
surprises", Harvard Business School Press, 2004.6Zero risk illusion
Easiest way that started to persuade stakeholders
Regulators became involved, though they should not have
been done.
They themselves trapped by "Safety myth" and captured to
think 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"
Safety Myth7"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 March
in 2006 ....
The WG initially aimed to introduce the concept of PAZ (Precautionary
Action Zone). However, the WG met with a strong opposition from
NISA... :
... 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 5-
km radius... "Safety Myth"
... if IAEA’s approaches ... are introduced, ... the local residents
there would be forced to consider relocation ... ; this would cause
significant social confusion and foster a perception that the existing
... measures based on EPZ is insufficient ... "Don’t wake a
sleeping child", "Bureaucracy", etc. Government‘s Final Report8Easy Option
From number of years ago, some experts in the field of
severe accident and emergency preparedness and
response keep questioning the decision-making system in
taking protective actions under emergency by overly
relying on source term prediction and dose projection
systems.
"Source term prediction at emergency is precise and
reliable enough" was another safety myth. Those systems
were an easy option for many.9Missed the Opportunities
Against SBO
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 the
Safety Design Guide ...
National Diet’s Report10Tsunami risk recognized
By 2006, NISA and TEPCO shared information on the possibility of a
SBO occurring at the Fukushima Dai-ichi plant .... They also shared an
awareness of the risk of potential reactor core damage from a loss of
seawater 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...
http://www.merriam-webster.com/dictionary/agile
Merriam-Webster "Agility"
marked by ready ability to move with quick easy grace
having a quick resourceful and adaptable character
Lack of Agility
National Diet’s Report11Omission 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 of
omission (doing nothing) than errors of commission
(causing harm).
They (operators and regulatory agencies) chose instead
to go the easy way, with the attitude: "Don’t disturb a
sleeping baby." They ... were meek in their efforts to
tackle 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
Bazerman, M. H., and Watkins, M. D., "Predictable
surprises", Harvard Business School Press, 2004.12Institutional 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., "Predictable
surprises", Harvard Business School Press, 2004.13... promotion of nuclear power came first in importance. ... Therein lies
the fundamental reason why the formulation and development of a
sound safety culture was hampered.
... for Japan’s regulators, "promotion" considerations took priority over
introducing new regulatory measures. They feared that new regulations
might call into question the validity of the safety measures that were in
place, raise the risk of defeat in lawsuits by anti-nuclear advocates, or
draw the unwelcome attention....
They stuck to their belief of infallibility so much that they were reluctant
to improve safety regulations...
Structural Problems
National Diet’s Report14Criticality accident at JCO plant in 1999
The root of this accident was lack or erosion of "crisis awareness" of
criticality accident. ...it is important to keep it in mind... To prevail this
crisis awareness in our society, we must change our consciousness
from "safety myth" or "absolute safety" into "risk informed safety
assessment".
Loss of institutional memory
Lapses in capturing lessons-learned, and long-term erosion of the
fabric of institutional memory due to personnel losses
Oblivious
Bazerman, M. H., and Watkins, M. D., "Predictable
surprises", Harvard Business School Press, 2004.
NSC’s Report on JCO criticality accident
at Tokai-mura, Dec. 199915NRA’s Efforts to foster Nuclear Safety Culture
NRA’s Core Values and Principles, Jan. 2013
Transparency through live video on the web and disclosure of
documents
• 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 three
phases 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16NRA’s Core Values and Principles
Statement of
Nuclear Safety Culture
Code of Conduct
on Nuclear Security
Structure of NRA’s Mission Statements in its Management System
NRA’s Statement of Nuclear Safety Culture
Issued on May 27, 2015
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17The 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 thorough
transparency, and recently issued a statement of nuclear safety culture.
The accident keeps being a distinct memory at present. All the NPPs are
still shut-down status, and nation-wide, furious discussions about re-start
are going on. Accordingly, activities in the NRA get a lot of attention, and
sense 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 "safety
first" can survive.
Closing remarks
That’s all for my talk regarding safety culture
of regulatory body...
In addition, the following slides describe our
on-going reform of inspection, particularly
about licensee’s safety culture19IRRS Mission
The Integrated Regulatory Review Service (IRRS) team
performed a mission (Jan. 11-22, 2016) to assess the
regulatory framework for nuclear and radiation safety in Japan.20The IRRS team identified good practices:
The swift establishment of a legal and governmental
framework that supports a new independent and
transparent regulatory body with increased powers.
NRA’s prompt and effective incorporation of lessons
learned from the Fukushima Dai-ichi accident in the areas
of natural hazards, severe accident management,
emergency preparedness and safety upgrades of existing
facilities, into Japan’s new regulatory framework.
Good Practices
IAEA, "IAEA Mission Says Japan’s Regulatory Body Made Fast Progress, Sees Challenges Ahead", March 2016
https://www.iaea.org/newscenter/pressreleases/iaea-mission-says-japan%E2%80%99s-regulatory-body-made-fast-
progress-sees-challenges-ahead21The NRA should work to attract competent and
experienced staff, and enhance staff skills relevant to
nuclear and radiation safety through education, training,
research and enhanced international cooperation.
Japanese authorities should amend relevant legislation to
allow NRA to perform more effective inspections of nuclear
and radiation facilities.
The NRA and all entities it regulates should continue to
strengthen the promotion of safety culture, including by
fostering a questioning attitude.
Examples of
Recommendations and Suggestions
IAEA, "IAEA Mission Says Japan’s Regulatory Body Made Fast Progress, Sees Challenges Ahead", March 2016
https://www.iaea.org/newscenter/pressreleases/iaea-mission-says-japan%E2%80%99s-regulatory-body-made-fast-
progress-sees-challenges-ahead22Recommendation on Inspection
Integrated Regulatory Review Service (IRRS) Mission to Japan, Tokyo, Japan, 10-22 January 2016, IAEA
The government should improve and simplify the
inspection framework to:
• Increase NRA flexibility to provide for efficient,
performance based, less prescriptive and risk
informed regulation of nuclear and radiation safety;
• Ensure NRA inspectors have formal rights for free
access to all facilities and activities at any time;
NRA should develop and implement a program of
inspection ...... specifying types and frequency of
regulatory inspections (including scheduled inspections
and unannounced inspections) in accordance with a
graded approach.23Bill for Amendment of
Relevant Acts on Inspection, etc.
Submitted to the Diet on Feb. 7, 2017
Aiming at
Inspection framework leading to continuous improvement
of safety through the licensees’ efforts for enhancing
safety even beyond the regulatory requirements
• Clarification of licensee’s prime responsibility for safety
• Performance-based approach, ......
Comprehensive regulatory oversight/assessment and
taking actions based on its results, not checking every
detail of pre-determined items
• Assess licensee’s activities anytime and anywhere
• Unify/simplify current various inspection categories24Importance to capture early warning sign of declining safety culture.
One of the most difficult challenge in assessing the safety performance
is to recognize the early signs of declining safety performance, before
... a serious incident or accident occurs.
The indicators are at such a high level that they give few clues
regarding the underlying weaknesses causing the declining
performance.
OECD/NEA CNRA Green Booklets, Improving Nuclear Regulation, 2009
Early signs of apparent
safety problems
Persistent signs of
problems
Clear operational
safety problems
Enhanced regulatory
attention
Follow-up regulatory
problems Regulatory intervention
Weak Safety Culture
Declining Safety
Performance Safety Problems
How to Evaluate Licensee’s Safety Culture25Licensee has been required to describe its activities for
fostering safety culture in its Operational Safety Program
since December, 2007.
The Operational Safety Inspection is being done every
quarter of year to check licensee’s compliance with its
Operational Safety Program where the Safety Culture Guide
is being used.
Revision of the Guide is in progress:
• Consistency with GSR Part 2 (Leadership, management,
integrated management system (IMS), etc.)
• More emphasis on role/responsibility of management
Guide for regulatory body to evaluate the licensee’s efforts to prevent
degradation of safety culture and organizational climate (Dec. 2007)
Safety Culture Guide
https://www.nsr.go.jp/data/000170836.pdf26M. Makino, Y. Ishii, International
Congress on Advances in Nuclear
Power Plants (ICAPP 09), Tokyo
Japan, May 12, 2009
Safety Culture Traits Used in the Guide
1. Commitment of top management
2. Clear policies and performances of senior managers
3. Measures to avoid wrong decision-making
4. Persistent questioning attitude
5. Reporting culture
6. Good communication
7. Accountability and transparency
8. Compliance
9. Learning organization
10. Organization making efforts for preventing
accidents/minor events
11. Self-assessment or third-party review
12. Work control and management
13. Change management
14. Attitude and motivation27Based on the licensee’s plan and indicators for capturing
the symptom of safety culture degradation at beginning of
a year, monitor the licensee’s activities and accumulate
the findings throughout the year
At the end of the year, analyze the findings based on the
14 traits, and identify the weaknesses of the organization
(Step 7)
Through the discussion with the licensee, decide the items
requiring for further efforts (Step 8)
Identify good practices from the findings (Step 9)
Perform comprehensive evaluation throughout the year
(Step10)
Evaluation Process of Licensee’s Activities
for Fostering Safety Culture
M. Makino, Y. Ishii, International Congress on Advances in
Nuclear Power Plants (ICAPP 09), Tokyo Japan, May 12, 2009
Stage Step Actions
Preparation
Stage1Check the licensees’ action plan and indicators for
safety culture activities2Check the licensee’s indicators for capturing the
symptom of safety culture degradation
Inspection
Stage
3 Identify, if any, the symptoms of safety culture
degradation during daily patrol, etc.4Identify, if any, the symptoms of safety culture
degradation from results of root cause analyses
Evaluation
Stage5Review the results of licensee's activities for fostering
safety culture6Review the results of indicators for capturing the
symptom of safety culture degradation
7 Elicit the items necessary to enhance licensee's efforts8Taking into account the discussion with licensee, decide
and present the licensee the items requiring for further
efforts
9 Identify good practices
10 Consolidate comprehensive assessment
Thank you for your attention!
With thanks to
Masashi Hirano
Shuichi Kaneko
Shinya ItoNRA