When engineering professor Yotaro Hatamura took the job of heading the independent investigation into the Fukushima disaster, he said he was looking for lessons rather than culprits. He may have changed his mind.
In a 507-page report published yesterday after a six-month investigation, Hatamura reserves some of his strongest criticism for Japan’s atomic power regulator, the Nuclear Industrial and Safety Agency, known as NISA.
NISA officials left the Dai-Ichi nuclear plant after the March 11 earthquake and when ordered to return by the government provided little assistance to Tokyo Electric Power Co. staff struggling to gain control of three melting reactors, according to the report.
“Monitoring the plant’s status was the most important action at that time, so to evacuate was very questionable,” the report by Hatamura’s 10-member team concluded. The committee found “no evidence that the NISA officials provided necessary assistance or advice.” Even though NISA’s manual said to stay at the plant, their manager allowed the officials to evacuate, according to the report, which doesn’t name the manager.
The preliminary conclusions by Hatamura, who specializes in studies of industrial accidents caused by design flaws and human error, includes a slew of planning failures, breakdown in communication and operational mistakes by Tokyo Electric and the government before and after the earthquake and tsunami.
While the utility supplied the electricity that kept homes, factories and offices running in metropolitan Tokyo, the world’s biggest city, lack of preparation for power failure in the Fukushima station left workers reduced to flashlights at the 864-acre plant site, the size of about 490 soccer fields.
Batteries in cell phones at the Fukushima plant started running out on March 11 and with the failure of mains power couldn’t be recharged, preventing communication with the on-site emergency headquarters, according to the report.
Because the utility known as Tepco hadn’t considered a tsunami overwhelming the Fukushima plant, no preparation was made for “simultaneous and multiple losses of power” causing station blackout, the document says. As a result, the operational manuals lacked information to help staff restore equipment or power.
The blackout caused the failure of all personal handyphone system units in the plant, seriously disrupting communications among workers.
Communications became so fractured that plant manager Masao Yoshida, stationed in the emergency bunker, didn’t know what some workers were doing. The high pressure coolant injection system at the No. 3 reactor was stopped by a worker without authority from plant managers, according to the report. The reactor was one of the three that melted down.
In Tokyo, the central government’s response was muddled by miscommunication between two teams working on different floors of the same building, the report said.
The report also criticized the government for failing to use its system for monitoring the spread of radiation in calculating evacuation areas. While the monitoring tool lacked sufficient data for an accurate assessment because of communication failures, its predictive functions should have been used, the report said.
The government also erred in keeping data on the spread of radiation from the public. “Information on urgent matters was delayed, press releases were withheld, and explanations were kept ambiguous,” the report concluded.
The report by Hatamura, professor emeritus at University of Tokyo, serves as a time line for the chaos that ensued when the record magnitude-9 earthquake knocked out power and buckled roads before the tsunami flooded backup generators. Radiation fallout from the reactors forced the evacuation of about 160,000 people. The government hasn’t said how many can return and when.
“Tepco, NISA and the government will brace themselves as the interim report condemned them all,” Tomoko Murakami, a nuclear researcher at the Institute of Energy Economics in Tokyo, said today by telephone. “They will be forced to improve safety measures to reflect what the report pointed out, such as Tepco’s useless manuals.”
Tepco takes the investigation report seriously, Osamu Yokokura, a spokesman for the utility, said by phone today.
“The government committee has done a thorough investigation, the report didn’t have many differences from what we have found,” he said.
Hotlines between the central control room and the reactor buildings worked following the quake, while workers outside the buildings had a total of nine transceivers, spokesman Masato Yamaguchi said yesterday. The company added 29 transceivers on March 13 and 80 more on March 15, Yamaguchi said.
On NISA procedures, the report says the agency’s manual called for inspectors to remain at Dai-Ichi in an emergency while other officials head to the offsite emergency command office 5 kilometers (3 miles) away in Okuma town.
By March 14, all eight NISA officials, who are unidentified in the report, had left Dai-Ichi.
“The inspectors were in charge of gathering live information on the site,” Hiroyuki Fukano, director-general of NISA, told reporters in Tokyo last night. “It’s a serious problem that they didn’t do their job, though it’s a matter of NISA’s system, rather than individual inspectors,” said Fukano who was appointed after the former head, Nobuaki Terasaka, was fired in August.
Leaving the Plant
Kazuma Yokota, NISA’s chief inspector at Dai-Ichi at the time of the quake, said in an interview with Bloomberg News in April he was one of three inspectors who left the plant 15 minutes after the temblor for Okuma. The three reached the center in 15 minutes and found it wrecked, power down and no working communications, he said.
A person who answered a call to Yokota’s cell phone yesterday said it was a wrong number. An official reached by phone in NISA’s office in Fukushima said Yokota was not available.
“People are often unaware of the functions of the organizations they belong to,” Hatamura told reporters yesterday. “If you don’t understand that function, you can’t live up to the expectations that people put on your organization. This is basically what happened at NISA after the accident.”
Prime Minister’s Questions
Hatamura’s full report is expected in the summer of 2012, when it will include interviews with former Prime Minister Naoto Kan and other Cabinet officials. Those interviews weren’t completed for the interim report due to time constraints, according to a briefing by the Ministry of Economy, Trade and Industry last week.
The committee interviewed 456 people over a total of 900 hours of hearings by Dec. 16, according to the report.
Interviewing Kan may be necessary to reach a conclusion on media reports that former Tepco President Masataka Shimizu requested to evacuate all employees from the plant following the disaster.
Tepco has denied it made that request, while Hatamura’s report said the company was planning a “partial evacuation.”
Hatamura was appointed by the government in May to lead an “impartial and multifaceted” investigation into the nuclear accident, the worst since Chernobyl in 1986.
‘Learning from Failure’
He received his Ph.D. in industrial mechanical engineering from the University of Tokyo in 1973 and began studying human error after finding his students were more interested in how projects can go wrong, according to the publisher of his book “Learning from Failure.”
The Failure Knowledge Database that he set up has studies on more than 1,100 accidents, including a case study of Tokyo Electric and its falsification of nuclear plant maintenance records, which the utility admitted in 2002. The study concludes the faked reports resulted from lack of quality control and proper risk management.
The disaster at Dai-Ichi shows the need for a “paradigm shift in the basic principles of disaster prevention” at nuclear power plants, Hatamura’s committee concluded in the report. “It’s inexcusable that a nuclear accident couldn’t be managed because a major event such as the tsunami exceeded expectations.”