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Chernobyl's 30th Anniversary (and Fukushima's 5th): A Tale of Preventable Nuclear Accidents and the Vital Role of Safety Culture

ICE Graveyard 22/04/2016 Najmedin Meshkati
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"Those who cannot remember the past are condemned to repeat it..."
George Santayana

The world commemorates the 30th anniversary of the Chernobyl nuclear power plant catastrophic accident in Ukraine on April 26, 2016. However, I believe that this event, by itself, doesn't do justice to the enormity and impact of this plant on the world, as I saw and felt about it in 1997, even after seeing the aftermaths of the Fukushima Daiichi nuclear accident in November 2012.
When I got the first sight of the sarcophagus of the Chernobyl nuclear power station while being driven in the exclusion zone toward the plant in a bright day in May 1997, I felt that Chernobyl was domineering, amazing, captivating, stunning and mesmerizing. Like a mysterious temple of eternal doom which "radiates" supernatural power, its eerie presence commanded respect, and its ominous sarcophagus demands solemnity. Spending a few days in the control room of, then operating, Reactor No. 3, which was identical to the exploded No. 4 and mingling with its operators, was another quintessential experience.
The long-distance travelling fallout and wide-reaching aftermath of this accident has been characterized as "a nuclear accident anywhere is a nuclear accident anywhere."
I think there is no other site, or any other structure on earth, that has had such a devastating effect on the lives of millions of people and on the environment. Going through the Exclusion Zone, seeing the sarcophagus from a very close distance, visiting the (deserted, ghost) town of Pripyat, talking with "liquidators" and discussing nuclear safety issues with the general director and his deputy in charge of the sarcophagus, reconfirmed my conviction, more than ever, that our interdisciplinary effort research on the risk mitigation of technological systems has the potential to offer a lot to humanity.
A Key Root-Cause of the Chernobyl Accident - Safety Culture
According to many seminal studies by the International Atomic Energy Agency (IAEA) and other sources (to be cited later), the root cause of the Chernobyl nuclear power plant accident was attributed to a primarily deficient safety culture, not only at the Chernobyl plant but also throughout the Soviet design, operating and regulatory oversight for nuclear power that existed at the time of accident in 1986.
The safety culture is typically defined as the assembly of characteristics and attitudes in organizations and individuals that establishes that, as an overriding priority, safety issues receive the attention warranted by their significance. The US Nuclear Regulatory Commission (NRC) and the nuclear power industry's Institute of Nuclear Power Operations (INPO), have jointly defined safety culture as:
"Nuclear safety culture is defined as the core values and behaviors resulting from a collective commitment by leaders and individuals to emphasize safety over competing goals to ensure protection of people and the environment....For the commercial nuclear power industry, nuclear safety remains the overriding priority" [All emphases in the original.]

Creating and nurturing a positive safety culture basically means to instill thinking and attitudes in organizations and individual employees that ensure safety issues are treated as high priorities. A plant fostering a safety culture would encourage employees to cultivate a questioning attitude and a rigorous and prudent approach to all aspects of their job -- and would set up necessary open communications between line workers and mid and upper management.
The following section includes a representative samples and noteworthy snippets from credible, influential sources to further corroborate above contention:
According to the International Atomic Energy Agency's (IAEA) Nuclear Safety Review for 1987 [p. 43]:
"The Chernobyl accident illustrated the critical contribution of the human factor in nuclear safety".

According to the IAEA's Summary Report on the Post-Accident Review Meeting on the Chernobyl Accident [p. 76]:
"The root cause of the Chernobyl accident, it is concluded, is to be found in the so-called human element.... The lessons drawn from the Chernobyl accident are valuable for all reactor types."

According to the IAEA's International Nuclear Safety Advisory Group (INSAG), The Chernobyl Accident Updating of INSAG-1 [p.24]:
"The (Chernobyl) accident can be said to have flowed from deficient safety culture, not only at the Chernobyl plant, but throughout the Soviet design, operating and regulatory organizations for nuclear power that existed at the time...Safety culture...requires total dedication, which at nuclear power plants is primarily generated by the attitudes of managers of organizations involved in their development and operation."

And finally, according to the late Academician Dr. Valeri A. Legasov, the First Deputy Director of the Kurchatov Institute at the time of the Chernobyl accident, and the head of the former Soviet delegation to the Post-Accident Review Meeting of the IAEA in August, 1986, quoted in Monipov [p. 340]:
"I advocate the respect for human engineering and sound man-machine interaction. This is a lesson that Chernobyl taught us."
The Fukushima Accident
It may come as a surprise to some people that the Fukushima Daiichi accident, which was caused by a natural disaster, the March 11, 2011 Tohoku earthquake and tsunami, was an anthropogenic accident. All investigations have concluded that Fukushima Daiichi was mostly preventable, and that the natural hazards acted only as a triggering mechanism for the ensuing disaster.
Also a recent study goes even further by asserting that "the Fukushima accident was preventable". In the words of Dr. Kiyoshi Kurokawa, chairman of the National Diet (Parliament) of Japan Fukushima Accident Independent Investigation Commission (NAIIC), Fukushima was "a man-made disaster" and "made in Japan". Because Japan's nuclear industry failed to absorb the lessons learned from Three Mile Island and Chernobyl nuclear accidents, "it was this mindset that led to the Fukushima Daiichi disaster". Other official reports on the Fukushima accident, such as the one by the US National Academy of Sciences, have also acknowledged and extensively discussed the instrumental role of safety culture in this accident.
Former US Nuclear Regulatory Commission (US NRC) Chairman, Dr. Allison M. Macfarlane at the International Nuclear Safety Group (INSAG) Forum (held at the IAEA, on Monday, September 17, 2012) stated:
"There are many lessons that we must all take away from the accident at Fukushima, but some of the most valuable extend beyond the technical aspects and are embedded in human and organizational behaviours. Among these is safety culture.
Lars Högberg, who was Director General of the Swedish Nuclear Power Inspectorate (SKI) (1989-1999) and also has served as a Governor of the IAEA (and a member of the INSAG; contributed to INSAG-15, 2002) and as Chairman of the Steering Committee of the OECD Nuclear Energy Agency, has conducted an excellent thorough analysis of the root causes and impacts of three severe accidents at large civilian nuclear power plants (the Three Mile Island, Chernobyl, and the Fukushima Daiichi) has concluded:

"All three severe accidents discussed in this paper had their root causes in system deficiencies indicative of poor safety management and poor safety culture in both the nuclear industry and government authorities."
Onagawa Nuclear Power Station - A Success Story of Proactive Corporate Safety Culture
It should be noted that Tohoku Earthquake and Tsunami on Tuesday March 11, 2011 had two drastically different impacts on TEPCO's Fukushima (Daiichi and Daini) nuclear power plants versus Tohoku Electric Power Company's Onagawa Nuclear Power Station. While the Fukushima and Onagawa power plants shared similar disaster conditions, nuclear reactor types (Boiling Water Reactor BWR, Mark I), dates of operation, and an identical regulatory regime, it was only Tohoku Electric's Onagawa power plant that went unscathed. Fukushima Daini was damaged by the earthquake and severely hit by the tsunami, but thanks to the heroic efforts of its operators and their epic improvisation managed the cold shutdown of all its four operating reactors. On the other hand, Fukushima Daiichi plant experienced a fatal meltdown and radiation release while Onagawa managed to remain generally intact, regardless of its proximity to the epicentre of the enormous earthquake.
Everyone knows the name Fukushima, but even in Japan few people are familiar with the Onagawa power station. Fewer still know how Onagawa managed to avoid a disaster. According to a report by the International Atomic Energy Agency mission that visited Onagawa and evaluated its performance, "the plant experienced very high levels of ground motion--the strongest shaking that any nuclear plant has ever experienced from an earthquake," but it "shut down safely" and was "remarkably undamaged."
Why is there such a stark contrast? How Oangawa weathered the tsunami relatively unscathed, while Daiichi didn't? Answers to these vexing questions and lessons learned are important for every operating and under-construction nuclear reactor in the world.
Most people believe that Fukushima Daiichi's meltdown was predominantly due to the earthquake and tsunami. The survival of Onagawa, however, suggests otherwise. Onagawa was only 123 kilometres away from the epicentre, 60 kilometres closer than Fukushima Daiichi, and the difference in seismic intensity at the two plants was negligible. Furthermore, the tsunami was bigger at Onagawa, reaching a height of 14.3 meters, compared to 13.1 meters at Fukushima Daiichi. The difference in outcomes at the two plants reveals the root cause of Fukushima Daiichi's failures a corporate "safety culture".

Finally, according to a most recent voluminous report on the Fukushima accident by the International Atomic Energy Agency (IAEA), the regulation guidelines and procedures were not adequate concerning safety culture, and it stated that "it is necessary to take an integrated approach that takes account for complex interactions between people, organizations and technology" [p.67]. And the IAEA Director General, Mr. Yukiya Amano, has asserted (p.7):
"There can be no grounds for complacency about nuclear safety in any country. Some of the factors that contributed to the Fukushima Daiichi accident were not unique to Japan. Continuous questioning and openness to learning from experience are key to safety culture and are essential for everyone involved in nuclear power. Safety must always come first." (emphasis added)

It seems that human performance and organizational factors were "recurring" themes and constituting major root-causes of past sever nuclear accidents - starting from the SL1 in 1961 all the way to the Fukushima Daiichi in 2011. And Fukushima Daini was only saved because of the heroic efforts and skilful improvisation of its dedicated operators and Onagawa went unscathed because of the proactive organizational safety culture of its utility.
A Flashback to 1961 and 1979- The SL1 (Stationary Low Power Reactor No. 1) and Three Mile Island Nuclear Accidents
Past events and history of sever nuclear accidents have demonstrated that human and organizational factors play a crucial/vial role in the safety of nuclear power plants around the world.
The accident on January 1961 at the SL1 (Stationary Low Power Reactor No. 1), located at the National Reactor Testing Station, Idaho Falls, Idaho, could be considered as one those early accidents which involved fatality. A 1964 quotation from the general conclusions as to the causes of this accident could, as well and almost exactly, be applied to the Three Mile Island and Chernobyl cases [As such, one may argue that should it be heeded, these accidents could have been prevented]:
"Most accidents involve design errors, instrumentation errors, and operator or supervisor errors... The SL1 accident is an object lesson on all of these... There has been much discussion of this accident, its causes, and its lessons, but little attention has been paid to the human aspects of its causes... There is a tendency to look only at what happened, at to point out deficiencies in the system without understanding why they happened; why certain decisions were made as they were... Post-accident reviews should consider the situation and the pressures on personnel which existed before the accident"

According to the Nuclear Regulatory Commission's authoritative investigation of the Three Mile Island nuclear power plant accident which was published in 1980:

"The one theme that runs through the conclusions we have reached is that the principal deficiencies in commercial reactor safety today are not hardware problems, they are management problems."
Last Words - Lessons Learned and a Gentle Reminder for the New Nuclear Countries/Regions of China and the Persian Gulf
It seems that the same common, recurring theme echoes in all named nuclear accidents - SLI, TMI, Chernobyl, and Fukushima - in this article.
Most important and unequivocal lesson of the past tumultuous history of nuclear power in the world is: Human factors and safety culture can make or break nuclear power plants or any safety-critical system; and operators' individual mindfulness and improvisation potential need to be nurtured and cultivated by the organizations that operate such systems; and regulatory regimes should envision, encourage, and enforce them. Let's hope that under the IAEA's stewardship some 30 years after the Chernobyl accident, the global nuclear power industry, as a whole, has internalized the defining feature of high-reliability organizations (HRO) - "preoccupation with the possibility of failure" - and has achieved the needed "collective mindfulness", at both the plant and industry levels, to not only remember but also heed and operationalize the above vital lesson; otherwise, as the epigraph of this essay by the renowned Spanish-American philosopher and essayist George Santayana, pointed out:

"Those who cannot remember the past are condemned to repeat it..."

Najmedin Meshkati, a professor of engineering and international relations at the University of Southern California (USC), conducts research on technological systems safety and has visited many nuclear power stations around the world, including Chernobyl (1997), Mihama (1999), and Fukushima Daiichi and Daini (2012). He severed as a Member (2012-2013) and Technical Advisor (2013-2014) on the U.S. National Academy of Sciences/National Research Council Committee on Lessons Learned from the Fukushima Nuclear Accident for Improving Safety and Security of U.S. Nuclear Plants. This commentary, however, should not necessarily be construed as the entire Committee's representative position. This essay has been extracted from an extensive research article, entitled, "Operators' Improvisation in Complex Technological Systems: The Last Resort to Averting an Assured Disaster", by N. Meshkati and Y. Khashe, which was presented at the International Atomic Energy Agency's International Conference on Human and Organizational Aspects of Assuring Nuclear Safety - Exploring 30 Years of Safety Culture, February 22-26, 2016, Vienna, Austria.

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