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Six questions to learn from the Fukushima disaster through Human and Organizational Factors

The accident which was triggered at Fukushima Daiichi nuclear power plant on March 11, 2011 in the wake of a massive earthquake and tsunami is the worst nuclear accident since Chernobyl. Four years later, as more witness accounts become available, IRSN feels useful to return to the human and organizational response to the accident inside the NPP itself.

Starting from the official reports and testimonies on the Fukushima accident, IRSN has published a report entitled “Human and Organizational Factors Perspective on the Fukushima Nuclear Accident”.

Download the full report PSN-SRDS / SFOHREX n°2015-01 “Human and Organizational Factors Perspective on the Fukushima Nuclear Accident” (PDF, 2,13 Mo)

Download the summary report PSN-SRDS / SFOHREX n°2015-03 “Six questions to learn from the Fukushima disaster through Human and Organizational Factors” (PDF, 0,9 Mo)

Human and organizational factors were key in determining the way the Fukushima Daiichi accident unfolded. With circumstances completely unforeseen in the manuals and procedures, actions at every level of the response structure – shift team, plant, utility, national emergency response – were determined by individual decisions and group dynamics.

By looking at each level as well as the relationships between them, this report describes the way the organizational structures and their accident management procedures contribute to or hinder the resolution of the crisis.

Methodology of the report

Six essential questions regarding the human and organizational factors (HOF) has been used to identify the principles and rules of action that the stakeholders applied in response to the accident and, more generally, to learn from this accident in terms of the HOF involved.

First, the report focusses on the Main Control Room, most notably the reactor 1 crew - questions 1 and 2- , then on its relationship with the plant Emergency Response Center - questions 3, 4 and 5 -  and lastly, on the political sphere - question 6.

For each question, IRSN presents the sequence of events and analyze the “mechanisms guiding the action” (the organizational and human dynamics) and identify the lessons to be learned from the accident and to highlight themes requiring further exploration by the HOF experts on crisis management.

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