How to improve safety in regulated industries - The nuclear accident in Fukushima
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How to improve safety in regulated industries - The nuclear accident in Fukushima

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  • 1. Eidgenössisches Nuklearsicherheitsinspektorat ENSIHow to improve safety inregulated industriesThe nuclear accident inFukushima Presentation for October 16th 2012 Content 1. The accident - General Overview 2. ENSI – Reports 3. 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. Conclusion 6. Final words Presentation October 16th 2012 2 F. Meynen, Section Head ENSI - MEOS 1
  • 2. Earthquake on March 11th, 2011Power 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 in decommissioning phase)Presentation October 16th 2012 3F. Meynen, Section Head ENSI - MEOSEarthquake on March 11th, 2011Industrial sites Refinery in Ichihara Oiltank in Minami SomaPresentation October 16th 2012 4F. Meynen, Section Head ENSI - MEOS 2
  • 3. Earthquake on March 11th, 2011Infrastructure Access difficulties – Heavily damaged roadsPresentation October 16th 2012 5F. Meynen, Section Head ENSI - MEOSEarthquake on March 11th, 2011Consequences for Nuclear Power StationsPresentation October 16th 2012 6F. Meynen, Section Head ENSI - MEOS 3
  • 4. Tsunami on March 11th, 2011 Transport infrastructure Airport of Sendai Port of Kamaishi Presentation October 16th 2012 7 F. Meynen, Section Head ENSI - MEOSTsunami on March 11th, 2011Flood wave at Fukushima site Presentation October 16th 2012 8 F. Meynen, Section Head ENSI - MEOS 4
  • 5. Tsunami on March 11th, 2011 Hydrogen Explosions Presentation October 16th 2012 9 F. Meynen, Section Head ENSI - MEOS ENSI reports about Fukushima accident Event Human and Lessons learned Radiology Sequences organisational factors and checkpointsThese reports are available on ENSI website: www.ensi.ch – Dossiers Presentation October 16th 2012 10 F. Meynen, Section Head ENSI - MEOS 5
  • 6. ENSI Action Plan FukushimaAction Plan ENSI – Focus in 2012 1. Earthquake 2. Flooding 3. Extreme weather conditions 4. Long term station blackout (SBO) 5. Lost of the ultimate heat sink 6. Containment-pressure relief and hydrogen management 7. Emergency management in Switzerland 8. Safety culture 9. Experience feedback 10. International oversight and cooperation 11. External storage facility (Reitnau, Switzerland) Presentation October 16th 2012 11 F. Meynen, Section Head ENSI - MEOS Human and organisational factors ENSI - Analysis 1. Origin and development of the accident Why did a Station Blackout (SBO) occur on 11 March 2011 after the earthquake and the tsunami? 2. Management of the accident Why did damage occur to the fuel assemblies and why did all the safety barriers fail, with the subsequent release of massive amounts of radioactivity into the environment? 3. Consequences of the accident Why were the plant staff and the public exposed and why was the environment contaminated? Presentation October 16th 2012 12 F. Meynen, Section Head ENSI - MEOS 6
  • 7. Origin and development of the accident Why did a Station Blackout (SBO) occur on 11 March 2011 after the earthquake and the tsunami? Two kinds of explanations from a Human Factors perspective within a whole set of hypotheses laid out in the ENSI - AnalysisAspects related to Aspectsstrategy and practice Insufficient Overall difficulty to related to independence of the consider possible anof government regulatory body event which has a low safety culturesupervision probability to occur Structural Oveerall deficiencies in the unfavorable overall supervision Inappropriate corporate culture system measures to Complacency and excessive trust protect the plant Deficiencies in the against a tsunami supervision of Conflict between emergency measures safety and cost andin the underlying efficiency legislative and regulatory framework Deficiencies regarding Insufficient the development of a supervision culture of learning in the organisation Presentation October 16th 2012 13 F. Meynen, Section Head ENSI - MEOS EU-Stresstest Medienkonferenz, 10. Januar 2012 – R. Sardella (ENSI) 13 Nuclear supervision and energy policy in Japan Origin and development of the accident Background 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! Presentation October 16th 2012 14 F. Meynen, Section Head ENSI - MEOS EU-Stresstest Medienkonferenz, 10. Januar 2012 – R. Sardella (ENSI) 14 7
  • 8. Management of the accident Why did damage occur to the fuel assemblies and why did all the safety barriers fail, with the subsequent release of massive amounts of radioactivity into the environment?Three kinds of explanations from a Human Factors perspective within a whole set of hypotheses laid out in the ENSI - Analysis Inappropriate measures to manage Organisational the plant during an accident with a Human aspects aspects cumulative loss of safety functions Documentation Presentation October 16th 2012 15 F. Meynen, Section Head ENSI - MEOS EU-Stresstest Medienkonferenz, 10. Januar 2012 – R. Sardella (ENSI) 15 Management of the accident Organisational aspects • Delayed decisions Complex crisis • Deficiencies in information and Organisation • protective measures of the general public 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 Presentation October 16th 2012 16 F. Meynen, Section Head ENSI - MEOS EU-Stresstest Medienkonferenz, 10. Januar 2012 – R. Sardella (ENSI) 16 8
  • 9. Management of the accident Human aspects Difficult to have an exact appreciation of the plant state due to loss of most of the information Difficulties to implement severe accident management 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 with 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 (between local and MCR / Crisis Center) Individual and collective stress Presentation October 16th 2012 17 F. Meynen, Section Head ENSI - MEOSEU-Stresstest Medienkonferenz, 10. Januar 2012 – R. Sardella (ENSI) 17 Management of the accident Documentation • …the risk of simultaneous destruction of all Procedures and infrastructure. Emergency plan insufficiently • …the lack of accessibility to certain equipment / systems. took into account … • …the inability to connect the installation with the mobile emergency power supply. Presentation October 16th 2012 18 F. Meynen, Section Head ENSI - MEOS 9
  • 10. Consequences of the accidentWhy 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 hydrogenDelays in the disclosure of information about radioactivity levels on-site and off-siteDelays to protect the publicTendency to communicate information which did not specify the risksThis demonstrates that it is still necessary to improve:Proactive information and communication on accidents and incidents; natural or industrialCommunication in crisis situations must satisfy the need of the population for clear andunderstandable information Presentation October 16th 2012 19 F. Meynen, Section Head ENSI - MEOSEU-Stresstest Medienkonferenz, 10. Januar 2012 – R. Sardella (ENSI) 19 Earthquake information Japan Meteorological Agency (JMA) Presentation October 16th 2012 20 F. Meynen, Section Head ENSI - MEOS 10
  • 11. Management of the accidentLessons learned from Fukushima from a Technical perspective Need to strengthen the protection of facilities against natural hazards Examples: • diverse power sources (off-site supply, external emergency power system, etc.) ensured by different cable routes • diverse water supply (wells, reservoirs, etc.) • better flood protection of the emergency diesels and associated cooling systems could have minimised the consequences of the tsunamiPresentation October 16th 2012 21F. Meynen, Section Head ENSI - MEOSComparison of building structuresLessons learned from Fukushima in a Technical perspectiveBackground informationPresentation October 16th 2012 22F. Meynen, Section Head ENSI - MEOS 11
  • 12. Safety featuresLessons learned from Fukushima in a Technical perspectiveBackground information «Defense in Depth» «Active Safety Systems» «Separation» «Redundancy» «Diversity» «Passive Safety Systems»Common Cause Failures (CCF):Failure of two or more structures, systems andcomponents due to a single specific event or cause.Common Mode Failure (CMF):Failure of two or more structures, systems and componentsin the same manner or mode due to a single event or cause. Presentation October 16th 2012 23 F. Meynen, Section Head ENSI - MEOSOperational experience feedbackLessons learned from Fukushima in a Technical perspectiveBackground informationBlayais, 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 Presentation October 16th 2012 24 F. Meynen, Section Head ENSI - MEOS 12
  • 13. 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 tasks successfully. The human performance is a result of all these factors during normal and accidental situations. All these factors have to be considered as “Factors of success” or “Failure factors”. During an accident, if these supports are not available or 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 be done so that the teams are best supported in managing situations that require emergency actions to protect the safety goals or to recover the safety functions. Presentation October 16th 2012 25 F. Meynen, Section Head ENSI - MEOSManagement of the accidentLessons learned from Fukushima from a Human Factors perspectiveWe do not mean here that the human factor is the “weakestlink”. On the contrary, in many situations, operators andorganisations are able to find “ultimate solutions”. But…beyond these exploits… we have to ensure that teams "always“ have information resources, control means, procedures, 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”. Presentation October 16th 2012 26 F. Meynen, Section Head ENSI - MEOS 13
  • 14. HF perspective Lessons learned from Fukushima eventWe need to continue: To adopt appropriate measures to protect the nuclear plants against the consequences of a severe accident exceeding standards taken into account during design (even if the probabilities of such events are very low) To have on- site and at the crisis centers, organisations with the knowledge to fully play their role efficiently This also includes cultural, organisational and individual capabilities to manage unexpected/unanticipated situations! Presentation October 16th 2012 27 F. Meynen, Section Head ENSI - MEOSEU-Stresstest Medienkonferenz, 10. Januar 2012 – R. Sardella (ENSI) 27 HF perspective Lessons learned from Fukushima eventWe need to continue: To take into account new knowledge & skills in regulatory requirements and safety guidelines To have on-site and in each crisis center means adapted 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 Presentation October 16th 2012 28 F. Meynen, Section Head ENSI - MEOSEU-Stresstest Medienkonferenz, 10. Januar 2012 – R. Sardella (ENSI) 28 14
  • 15. Conclusion• Taking into account extreme hazards • Independency• Appropriate technical and human • Protection of the population resources to cope with the event and the environment• Develop a good safety culture • Communication • Preparation for the management of crisis situations Autorities measures Utilities On site measures measures• Preparing staff training Exemplarity and Commitment• Appropriate materials and documents of all actors involved in safety• Exemplarity, responsibility and proactivity Presentation October 16th 2012 29 F. Meynen, Section Head ENSI - MEOS Final words Safety is not a state – Safety is a process Authority Environment Unit Presentation October 16th 2012 30 F. Meynen, Section Head ENSI - MEOS 15
  • 16. 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) Presentation October 16th 2012 31 F. Meynen, Section Head ENSI - MEOS Thank you very much for your attention! Presentation October 16th 2012 32 F. Meynen, Section Head ENSI - MEOS 16