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Failure Guru Probes Nuclear Crisis for Lessons Not Culprits

TEPCO Protesters
People march in front of the headquarters of Tokyo Electric Power Company (TEPCO) during an anti nuclear demonstration in Tokyo on June 11, 2011. Photograph: Toru Yamanaka/AFP/Getty Images

Engineering professor Yotaro Hatamura has built a career on failure.

The 70-year-old academic at the University of Tokyo founded the nonprofit Association for the Study of Failure in 2002, which has members including Tokyo Electric Power Co., the owner of the Fukushima plant at the center of the biggest nuclear accident since Chernobyl.

Tokyo Electric is now the subject of Hatamura’s next study. He was appointed by Prime Minister Naoto Kan last month as head of the 10-member team to conduct an “impartial and multifaceted” investigation into what went wrong at the Fukushima nuclear plant and how to prevent a repeat. He made a visit to the station yesterday.

His objectives are similar to those of U.S. President Barack Obama’s commission on the BP Plc Gulf of Mexico oil spill in 2010, which in January recommended “urgent reform” of government rules and oil industry practices. The independent Fukushima investigation team has the authority to question officials at Tokyo Electric and government leaders including the prime minister.

Independent of Influence

“I won’t be influenced by the positions of others or considerations of profit or loss,” Hatamura said at the team’s inaugural meeting on June 7 attended by Kan.

Hatamura also indicated his team will probe whether an earthquake-prone country such as Japan should have an energy policy built around atomic power. Because of the inherent dangers in nuclear power, it’s a mistake to treat it as being “safe,” he said at the meeting.

Trade Minister Banri Kaieda today said he may allow utilities to restart nuclear generators that had been shut down for routine maintenance. There are negatives to suspending all nuclear power, he said at a press briefing in Tokyo, citing an expected “gap” in power supply and demand in Japan’s coming summer months.

Tokyo Electric halted water decontamination today after five hours because a cesium-absorption unit needed replacement sooner than expected. The utility doesn’t know when it will be able to restart the system, Junichi Matsumoto, a spokesman for the utility, said at a news conference.

Water Contamination

Decontamination to reduce radiation in about 105 million liters (28 million gallons) of water in basements and trenches at the Fukushima Dai-Ichi nuclear plant was halted after the level of cesium in the absorption unit reached 4.7 millisieverts of radiation, Matsumoto said. The units generally need replacement at a level of 4 millisieverts, and the company had expected the unit to last about a month, he said.

On his return from Fukushima last night, Hatamura recounted a conversation with the plant’s manager, Masao Yoshida. “Yoshida told me that he could not imagine that such a big tsunami could come after an earthquake,” he told reporters in Tokyo. “From our discussions, I gathered that no one at the plant could imagine that such a tsunami would occur.”

Hatamura declined to be interviewed for this story.

Failure Database

The academic, who received his Ph.D in industrial mechanical engineering from the University of Tokyo in 1973, began his work studying human error after finding his students were more interested in learning how engineering projects can go wrong, according to the publisher of his book “Learning from Failure.”

The Failure Knowledge Database that Hatamura set up has studied 1,175 accidents using a method that focuses on design flaws, human error and how designers fail to see future changes in use.

Hatamura’s database has a case study of Tokyo Electric and its falsification of nuclear plant maintenance records, which the utility known as Tepco admitted in 2002. The study concludes the faked reports resulted from lack of quality control and proper risk management. He also examined the derailment of a commuter train in Amagasaki, western Japan that killed 107 people in 2005, according to the database.

Design Mistakes

Central to his research is the way machines are used over time and how designers fail to predict how the equipment will be adapted.

That showed in his investigation into the death of a six-year-old boy crushed in a revolving door in the Roppongi Hills building in central Tokyo in 2004.

The door technology was imported from Europe and modified before it was installed, Hatamura wrote in his study of the incident published with Komatsu Ltd. Where European designers had built the doors using aluminum to reduce weight and therefore their revolving force, the Japanese version used stainless steel to improve aesthetics and make them stronger.

The changes increased the “jamming force” of the door beyond the limit at which a human skull will crush, according to the report. The study concluded that “tacit knowledge” about the relationship between weight and revolving force was lost when the technology was imported by Japanese companies.

“Especially when a machine is automatic, the user’s lack of a sense of responsibility is leading to accidents that we did not see before,” he said in his report on the incident.

Crippling Blows

The Fukushima station suffered three reactor meltdowns after an earthquake and tsunami on March 11 knocked out power and backup generators, crippling its cooling systems.

The disaster displaced 50,000 households in the evacuation zone because of radiation leaks. Japan in April raised the severity rating of the crisis to 7, the highest on an international scale and the same as the Chernobyl disaster.

Tepco has been criticized its slow response to the accident and publishing erroneous radiation data, while the government-run Nuclear and Industrial Safety Agency has been blamed for not ensuring the utility heeded warnings that a tsunami could overwhelm the plant’s defenses.

Municipal authorities in Fukushima City have expanded radiation monitoring to 1,045 spots, from 100 observed earlier, the Yomiuri newspaper reported today. Concern rose among local residents after reports of so-called radiation hot spots outside the government-mandated exclusion zone around the plant, according to the report.

What, Not Who

While Hatamura has said the Fukushima probe will focus on what went wrong and not who is responsible, he will need to convince Tepco and government officials to tell all they know.

“The challenge will be how much information the people concerned will be willing to disclose,” said Shinichi Kamata, a professor of organization and strategy at the National Defense Academy of Japan, who serves on the safety advisory group of Japan Airlines Corp. with Hatamura.

The inclusion of a former chief prosecutor, a retired chief judge and a lawyer in Hatamura’s team raises concern that some investigators may want to identify individuals responsible, said Shigeru Haga, a professor of industrial psychology at Rikkyo University in Tokyo.

“I’m concerned they may hunt for suspects,” said Haga, fellow member of the Japan Airlines advisory group.

Debate for Courts

Other members of the panel include academics, a former diplomat, a radiology specialist, a writer and the mayor of a town in Fukushima prefecture.

Who is responsible is a debate for the courts, said Tomoaki Iwai, a political science professor at Nihon University.

“There may be lawsuits for legal judgments,” he said. “The purpose of this committee is to prevent an accident like this from happening again and set a safety standard for the future.”

Japan’s government pledged on June 7 “fundamental revision” of its nuclear safety rules and will create an independent regulator to prevent a repeat of the disaster.

A national debate is needed on the “whole concept of nuclear power generation,” the cornerstone of the country’s energy policy after World War II, the government said.

For Hatamura, accidents occur when the “human perception of risk” changes, he said in an East Japan Railway Co. report in 2006.

“We want this study into Fukushima to be something valuable 100 years from now,” he said this month. “This accident not only affects Japan but also people in the rest of the world.”

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