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Eidgenössisches Nuklearsicherheitsinspektorat ENSI
How to improve safety in regulated industries
The nuclear accident in Fukushima
Presentation for October 16th 2012
2Presentation October 16th 2012F. Meynen, Section Head ENSI - MEOS
Content
1. The accident - General Overview2. ENSI – Reports3. Human and organisational factors
• Origin and development of the accident• Management of the accident• Consequences of the accident
4. Management of the accident• Lessons learned from a Technical perspective• Lessons learned from a Human Factors perspective
5. Conclusion6. Final words
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3Presentation October 16th 2012F. Meynen, Section Head ENSI - MEOS
Earthquake on March 11th, 2011 Power Production
The earthquake on March 11th, 2011 at 14:46 caused the shutdown of several conventional and nuclear power stations.Nuclear sites:- Fukushima Daiichi (1 - 6)(unit 4 - 6 in outage)
- Fukushima Daini (1 - 4)- Onagawa (1 - 3)- Tokai 2 (unit 1 indecommissioning phase)
4Presentation October 16th 2012F. Meynen, Section Head ENSI - MEOS
Earthquake on March 11th, 2011 Industrial sites
Refinery in Ichihara Oiltank in Minami Soma
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5Presentation October 16th 2012F. Meynen, Section Head ENSI - MEOS
Earthquake on March 11th, 2011Infrastructure
Access difficulties – Heavily damaged roads
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Earthquake on March 11th, 2011 Consequences for Nuclear Power Stations
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Tsunami on March 11th, 2011Transport infrastructure
Airport of Sendai
Port of Kamaishi
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Tsunami on March 11th, 2011Flood wave at Fukushima site
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9Presentation October 16th 2012F. Meynen, Section Head ENSI - MEOS
Tsunami on March 11th, 2011Hydrogen Explosions
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ENSI reports about Fukushima accident
These reports are available on ENSI website: www.en si.ch – Dossiers
Event Sequences
Human andorganisational factors
Lessons learned and checkpoints
Radiology
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11Presentation October 16th 2012F. Meynen, Section Head ENSI - MEOS
ENSI Action Plan Fukushima
Action Plan
1. Earthquake 2. Flooding 3. Extreme weather conditions 4. Long term station blackout (SBO)5. Lost of the ultimate heat sink6. Containment-pressure relief and hydrogen
management7. Emergency management in Switzerland8. Safety culture9. Experience feedback10. International oversight and cooperation 11. External storage facility (Reitnau, Switzerland)
ENSI – Focus in 2012
12Presentation October 16th 2012F. Meynen, Section Head ENSI - MEOS
Human and organisational factorsENSI - Analysis
1. Origin and development of the accident
2. Management of the accident
3. Consequences of the accident
Why did a Station Blackout (SBO) occur on 11 March 2011 after the earthquake and the tsunami?
Why did damage occur to the fuel assemblies and why didall the safety barriers fail, with the subsequent r elease of massive amounts of radioactivity into the environme nt?
Why were the plant staff and the public exposed and whywas the environment contaminated?
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13Presentation October 16th 2012F. Meynen, Section Head ENSI - MEOS
EU-Stresstest Medienkonferenz, 10. Januar 2012 – R. Sardella (ENSI) 13
Origin and development of the accident
Aspects related to safety culture
Aspects related to strategy and practice of government supervision
Why did a Station Blackout (SBO) occur on 11 March 2011 after t he earthquake and the tsunami?
Two kinds of explanations from a Human Factors perspectiv e within a whole set of hypotheses laid out in the E NSI - Analysis
Inappropriatemeasures to
protect the plant against a tsunami
Overall difficulty to consider possible an
event which has a lowprobability to occur
Oveerallunfavorable
corporate culture Complacency and
excessive trust
Conflict between safety and cost
efficiency
Deficiencies regarding the development of a culture of learning in the organisation
Insufficient independence of the regulatory body
Structural deficiencies in the overall supervision
system
Deficiencies in the supervision of
emergency measures andin the underlying
legislative and regulatory framework
Insufficient supervision
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EU-Stresstest Medienkonferenz, 10. Januar 2012 – R. Sardella (ENSI) 14
Nuclear supervision and energy policy in JapanOrigin and development of the accidentBackground information
The structure of the Japanese nuclear sector is (was) very complex - a large number of different players!
Risk of lack of independence and transparency in the supervision of nuclear safety!
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15Presentation October 16th 2012F. Meynen, Section Head ENSI - MEOS
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Management of the accident
Organisationalaspects
Human aspects
Documentation
Why did damage occur to the fuel assemblies and why did all the safety barriers fail, with thesubsequent release of massive amounts of radioactivity int o the environment?
Inappropriate measures to manage the plant during an
accident with a cumulative loss of safety functions
Three kinds of explanations from a Human Factors perspect ive within a whole set of hypotheses laid out in the ENSI - Analysis
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Management of the accidentOrganisational aspects
• Delayed decisions• Deficiencies in information and • protective measures of the general public
Complex crisisOrganisation
Lack of clarity in the roles
Communications disrupted
Unsuitability of some crisis centers
Failures in communication between the two crisis centers in
the government building
Difficult to know or even to appreciate the situation on-site
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17Presentation October 16th 2012F. Meynen, Section Head ENSI - MEOS
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Management of the accidentHuman aspects
Difficult to have an exact appreciation of the plant state due to loss of most of the information
Difficulties to implement severe accident managemen t measures
• Environment conditions: aftershocks, plant damages, loss of electricity, radiological situation at the plant and in the MCR
• Number of people available at the site
• Difficult to implement actions
• Lack of protective measures for intervention teams
Difficulties to find how to restart safety functions wi th the tools and means available in a rapidly worsening stuation
• Operating crews are dependant on the tools and instruments available (or not available at the site)
• Lack of training
Difficulties to communicate during interventions (b etween local and MCR / Crisis Center)
Individual and collective stress
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Management of the accidentDocumentation
Procedures and Emergency plan
insufficiently took intoaccount …
• …the risk of simultaneous destruction of all infrastructure.
• …the lack of accessibility to certain equipment / systems.
• …the inability to connect the installation with the mobile emergency power supply.
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19Presentation October 16th 2012F. Meynen, Section Head ENSI - MEOS
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Consequences of the accident
Why were the plant staff and the public exposed and why was the environment contaminated?
Delays in the management of the event
• Cooling by injecting seawater• Release of steam• Control hydrogen
Delays in the disclosure of information about radio activity levels on-site and off-site
Tendency to communicate information which did not s pecify the risks
Delays to protect the public
This demonstrates that it is still necessary to imp rove:
Proactive information and communication on accident s and incidents; natural or industrial
Communication in crisis situations must satisfy the need of the population for clear and understandable information
20Presentation October 16th 2012F. Meynen, Section Head ENSI - MEOS
Earthquake informationJapan Meteorological Agency (JMA)
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21Presentation October 16th 2012F. Meynen, Section Head ENSI - MEOS
Management of the accidentLessons learned from Fukushima from a Technical per spective
Need to strengthen the protection of facilities against natural hazards
• diverse water supply (wells, reservoirs, etc.)
Examples:
• diverse power sources (off-site supply, external emergency power system, etc.) ensured by different cable routes
• better flood protection of the emergency diesels and associated cooling systems
could have minimised the consequences of the tsunami
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Comparison of building structuresLessons learned from Fukushima in a Technical persp ective Background information
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23Presentation October 16th 2012F. Meynen, Section Head ENSI - MEOS
Safety featuresLessons learned from Fukushima in a Technical persp ective Background information
Common Mode Failure (CMF):Failure of two or more structures, systems and components in the same manner or mode due to a single event or cause.
Common Cause Failures (CCF): Failure of two or more structures, systems and components due to a single specific event or cause.
«Redundancy» «Diversity»
«Separation»
«Defense in Depth»
«Passive Safety Systems»
«Active Safety Systems»
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Operational experience feedbackLessons learned from Fukushima in a Technical persp ective Background information
Blayais, 27.12.1999
Flood over the sea walls after combination of tide and high winds
Forsmark, 25.07.2007
Short circuit in the switchyard resulted in a severe disruption of the auxiliary and emergency power supply
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25Presentation October 16th 2012F. Meynen, Section Head ENSI - MEOS
Management of the accidentLessons learned from Fukushima from a Human Factors perspective
People which operate a plant need a lot of information , tools, instrumentation, protective measures, management support, documents, organisational and training measures… to be able to perform their taskssuccessfully.
The human performance is a result of all these factorsduring normal and accidental situations. All thesefactors have to be considered as “Factors of success” or “Failure factors”.
During an accident, if these supports are not availa bleor not completely usable / adequate for the situation , then the workers (individually and collectively) are “deprived”, whatever their commitment and motivation.
From a human factors perspective, everything must b e done so that the teams are best supported in managi ng situations that require emergency actions to protec t the safety goals or to recover the safety functions.
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Management of the accidentLessons learned from Fukushima from a Human Factors perspective
We do not mean here that the human factor is the “weakest link”. On the contrary, in many situations, operators and organisations are able to find “ultimate solutions”.
But…beyond these exploits… we have to ensure that teams "always“ have information resources, control means, procedur es, knowledge, ... to handle all possible events.
Otherwise, we need to give to the teams, the means which help them to ensure their role as “producers of reliability”.
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27Presentation October 16th 2012F. Meynen, Section Head ENSI - MEOS
EU-Stresstest Medienkonferenz, 10. Januar 2012 – R. Sardella (ENSI) 27
HF perspectiveLessons learned from Fukushima event
We need to continue:
To adopt appropriate measures to protect the nuclea r plants against the consequences of a severe acciden t exceeding standards taken into account during desig n (even if the probabilities of such events are very low )
To have on- site and at the crisis centers, organisa tionswith the knowledge to fully play their role efficie ntly
This also includes cultural, organisational and indi vidual capabilities to manage unexpected/unanticipated
situations!
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HF perspectiveLessons learned from Fukushima event
We need to continue:
To take into account new knowledge & skills in regu latory requirements and safety guidelines
To have on-site and in each crisis center means ada pted to allow teams to assess efficiently the state of the plant and
to continuously update this assessment
To develop and continuously optimize the conditions in which the human actions are performed by personnel
during emergency situations
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29Presentation October 16th 2012F. Meynen, Section Head ENSI - MEOS
Conclusion
• Independency• Protection of the population
and the environment• Communication• Preparation for the
management of crisis situations
• Taking into account extreme hazards• Appropriate technical and human
resources to cope with the event• Develop a good safety culture
• Preparing staff training• Appropriate materials and documents• Exemplarity, responsibility and proactivity
Exemplarity and Commitment of all actors involved in safety
Autoritiesmeasures
On site measures
Utilities measures
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Final words
Safety is not a state –
Safety is a process
Authority
Environment
Unit
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31Presentation October 16th 2012F. Meynen, Section Head ENSI - MEOS
Information Sources
• METI (Ministry of Economy, Trade & Industry) • NISA (Nuclear and Industrial Safety Agency)• TEPCO (Tokyo Electric Power Company)• JAIF (Japan Atomic Industrial Forum)• JMA (Japan Meteorological Agency) • IAEA (International Atomic Energy Agency)
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Thank you
very much
for your attention!