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Martin Ralph, Managing Director, Industrial Foundation for Accident Prevention (IFAP) - Organisational Culture: Case Study: lessons from Fukushima
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Martin Ralph, Managing Director, Industrial Foundation for Accident Prevention (IFAP) - Organisational Culture: Case Study: lessons from Fukushima

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Martin Ralph delivered this presentation at the Safety in Action 2014 Conference in Melbourne. This conference brings thought leadership and showcases topical, innovative safety methods and …

Martin Ralph delivered this presentation at the Safety in Action 2014 Conference in Melbourne. This conference brings thought leadership and showcases topical, innovative safety methods and practices.

For more information, please visit http://www.safetyinaction.net.au/SIA2014Melbourne

Published in: Health & Medicine
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  • 1. Lessons from Fukushima Daiichi Martin Ralph Managing Director
  • 2. • A Little About IFAP • What was Fukushima Daiichi? • What Happened at Fukushima Daiichi in 2011? • The Aftermath. • Lessons for the Safety Profession. • Reflections ... Presentation Outline © Copyright IFAP: 2014 SIA 2014: Fukushima 2
  • 3. Radiation Protection Specialist: • Mining and milling of radioactive ores; • Nuclear power generation and waste management a very different field. Have relied on “validated” sources: • Kenji Tateiwa, November 28th, 2012 • Manager, Nuclear Power Programs, Tokyo Electric Power Company, Washington Office • 4 Corners Documentary: Japan’s Nuclear Nightmare • Australian Broadcasting Commission, first broadcast 21st March, 2011 • International Atomic Energy Agency • IAEA Action Plan on Nuclear Safety, endorsed in September 2011 • Society of Radiological Protection • Journal articles from 1st June 2011 to 31st December 2013. Disclaimer © Copyright IFAP: 2014 SIA 2014: Fukushima 3
  • 4. IFAP is: • An independent, not for profit organisation; • Formed to provide leadership in the advancement of safety and health for the benefit of the WA workplace. • A Registered Training Organisation (#1907) since 5/4/2000 Commenced in 1962: • IFAP incorporated in1972. Senior Management report to a Board of Directors: • Comprised of leading figures drawn from major industry, government and academic institutions. A Little About IFAP © Copyright IFAP: 2014 SIA 2014: Fukushima 4
  • 5. Largest specialist OSH/WHS training provider in Australia: • Trained in excess of 10500 persons per year since 2001. • 24000 attendees at our face-to-face training events in 2013. Australian representative at: • Asia Pacific Occupational Safety and Health Organisation (APOSHO); • International Network of Safety and Health Practitioner Organisations (INSHPO). Proud Contributor to Body of Knowledge: • MR authored 2 chapters: – Physical Hazards: Ionising Radiation; and – Physical Hazards: Non Ionising Radiation A Little About IFAP © Copyright IFAP: 2014 SIA 2014: Fukushima 5
  • 6. What Was Fukushima Daiichi?
  • 7. Fukushima Daiichi © Copyright IFAP: 2014 SIA 2014: Fukushima 7 Fukushima Number 1 (Dai ichi) Nuclear Power Plant: • Operated by Tokyo Electric Power Company (TEPCO): − Largest electric utility in Japan. • Unit 1 Commissioned in 1971 v Unit 6 commissioned in 1979; • Boiling Water Reactors, different models due to period of commissioning; • 6 generating units (total capacity ~ 4.5 Gwe) − On 11th March, 2011, before earthquake:  Units 1,2 and 3 operating (capability 2 GWe);  Units 4, 5 and 6 in “outage” mode.  Unit 4 core had been offloaded to spent fuel pool. 2nd Nuclear Power Plant (Da ini) commissioned 1981-1986: – 4 Boiling water reactors, all operating, producing 4.4 Gwe.
  • 8. Daiichi and Daini © Copyright IFAP: 2014 SIA 2014: Fukushima 8 Daiichi Daini Both in the Futaba District of the Fukushima Prefecture: • 11.5 km apart, with coastal frontages. 30% of Japanese energy generated from NPP Daiichi
  • 9. E = mc2 (lots of heat generated from small mass): • Nuclear Fission (during operation); and Radioactive Decay (after shutdown). • Safety Principles: – 1.Shutdown; 2.Cool; 3.Contain. Boiling Water Reactor Basics © Copyright IFAP: 2014 SIA 2014: Fukushima 9
  • 10. What Happened at Fukushima on March 11, 2011?
  • 11. The Cause of the Tsunami SIA 2014: Fukushima 11© Copyright IFAP: 2014
  • 12. Friday, March 11th 2011 @ 2:46pm © Copyright IFAP: 2014 SIA 2014: Fukushima 12 Largest earthquake / tsunami in recorded history of Japan: • Magnitude 9.0 on Reichter Scale; • Epicentre offshore Sanriku Coast approx. 150-180km from Fukushima sites; • 20+ metre tsunami run-up observed on coast line; • Front was 200 km long. Hundreds of aftershocks (many on 11th March 2011):
  • 13. Shockwave and Fukushima Daiichi © Copyright IFAP: 2014 13SIA 2014: Fukushima
  • 14. Fukushima Daiichi 11/3/2011 @ 2:46pm © Copyright IFAP: 2014 SIA 2014: Fukushima 14 Earthquake impact: • Ground motion was comparable to design limits; • Plant responded as per design; • No confirmed damage to safety critical equipment or systems. Landslides and damage to substations, collapse of transmission line tower, etc. led to: • Loss of all site power at 1F; • Loss of all but 1 line of off-site power at 2F. 1F-5 1F-6
  • 15. Fukushima’s Big Problem © Copyright IFAP: 2014 15SIA 2014: Fukushima
  • 16. Broader Consequences © Copyright IFAP: 2014 SIA 2014: Fukushima 16 Great East Japanese Earthquake: • As well as 1F and 2F, the earthquake caused the shutdown of: – 7 Thermal power stations (12 generating units); – 25 Hydro power stations; and – 8 substations. • 40% of TEPCO power supply capacity lost (52 GWe down to 31 GWe); • 4 million households without power (14% of TEPCO’s customer base); • Massive infrastructure interruption (inc. Tokyo): – Public transportation; – Telecommunications; – Food and water supplies. • Approximately 19,000 people feared dead or missing.
  • 17. The Tsunami Arrives © Copyright IFAP: 2014 17SIA 2014: Fukushima
  • 18. Tsunami Arriving and Its’ Impact © Copyright IFAP: 2014 18SIA 2014: Fukushima
  • 19. The Aftermath
  • 20. Arrival of the Tsunami © Copyright IFAP: 2014 SIA 2014: Fukushima 20 Height (13-14m) far exceeded design specs (5.6-6.1m): • Extensive flooding led to station blackout in 5 of 6 units:
  • 21. © Copyright IFAP: 2014 SIA 2014: Fukushima 21 Water Innundation: Fukushima Daiichi
  • 22. And then ... © Copyright IFAP: 2014 SIA 2014: Fukushima 22 1. Back up batteries for cooling pumps had 8 hour life; 2. After 8 hours (max) • Loss of pumps = loss of supply of cooling water; 3. Loss of cooling water = increasing heat; 4. Increasing heat = increasing pressure and liberation of extremely explosive hydrogen; 5. Leading to the inevitable ...
  • 23. And then .... © Copyright IFAP: 2014 SIA 2014: Fukushima 23
  • 24. And then .... © Copyright IFAP: 2014 SIA 2014: Fukushima 24
  • 25. Fission Products, especially: • Iodine – 131, 132 and 133; Caesium – 134,136, and 137; • Tellerium – 132; and Xenon – 133. – Major concerns (Japan Nuclear Safety Commission estimates of released activity into the air)  I131 (T1/2 = 8.05 days, estimated 130 x 1015 Bq)  Cs137 (T1/2 = 30 years, estimated 11 x 1015 Bq) – ~ 27 x 1015 Bq Cs137 entered the ocean (French Institute for Radiological Protection)  Most important ocean emission of artificial radioactivity ever observed;  26/10/12 TEPCO – can’t stop radioactive material entering the ocean. Contaminated area requiring remediation = 13,000km2 How Much Radioactivity Was Released? © Copyright IFAP: 2014 SIA 2014: Fukushima 25
  • 26. The disaster displaced 50,000 households in the evacuation zone because of leaks of radioactive materials into the: • Air: – Inhalation hazard; • Soil: – Contamination of dwellings; – Possible food chain uptake. • Sea: – Possible food chain uptake. Community Impacts © Copyright IFAP: 2014 SIA 2014: Fukushima 26 1F uSv/h Between ~20 and 200 times Exposure Limit for Members of the Public No person received a dose that: • was lethal • will result in acute radiation sickness. WHO (2012) “people in the vicinity of the plant received such low doses that no discernible health effect could be expected”. The disaster displaced 50,000 households.
  • 27. Lessons for the Safety Profession
  • 28. Reasonably Practicable Based upon: • Forseeable-ness – an earthquake and resulting tsunami are forseeable; • Likelihood: – Japan most tsunami-prone region in the world (1every ~7 years); – previous HUGE tsunami in 869 Magnitude 8.4. • Cost to minimise or control risk: – Sea defences were 5.6m - 6.1m; – Even double this height, at presumably double the cost the defences would not have been sufficient. So – when is enough protection, enough protection? © Copyright IFAP: 2014 28SIA 2014: Fukushima
  • 29. Maxim v Myth Why didn’t Daini (F2) suffer the same fate? • Tsunami height peaked ~ 9m. – Not all power was lost; – Cold shutdown enabled. What about previous tsunami warnings? • “Tsunami warning stone”; • “Once in 400 year tsunami occurrence”; – Both refer to locations in Iwate Prefecture  300km North of Fukushima!  On a coastline that tends to magnify tsunami height. Why should the truth get in the way of a good story? © Copyright IFAP: 2014 29SIA 2014: Fukushima
  • 30. Technical Information © Copyright IFAP: 2014 SIA 2014: Fukushima 30 Radiation protection is a complicated technical field: • Extremely easy to make mistakes in normal circumstances; – Never mind when under pressure. • SI units are commonly used, but not in all jurisdictions: – e.g. US NRC cite dose limits in millirems (mR) http://www.nrc.gov/about-nrc/radiation/health-effects/info.html • SI unit for dose is the milliSievert (mSv); • Dose rates are often measured in microsieverts per hour (μSv/h). 100 millirem = 1 millisievert = 1000 microsievert • Try doing the backwards calculation “on the fly” – 20 mR = 0.2 mSv = 200 μSv • Cross border media often got the units (and others) muddled.
  • 31. Crisis Management © Copyright IFAP: 2014 SIA 2014: Fukushima 31 It appears TEPCO had an excellent crisis management plan; But they failed the communications test: • Accident in a highly technical process, not readily understood by the public. – Need to have a clear, simple, no BS message; • Lack of control saw accident scaled from INES Level 4 to 5 to 7. – 4 = accident with local consequences (12th March); – 5 = accident with wider consequences (18th March); – 7 = major accident (no higher level) = Chernobyl (12th April):  This gave the media a “handle” • Lack of clear communications strategy gave “pseudo-experts” oxygen: “...There is talk of apocalypse and I think the word is particularly well chosen” Gunther Oettinger, European Commissioner for Energy, March 15th 2011
  • 32. Reflections …
  • 33. Organisational Culture © Copyright IFAP: 2014 SIA 2014: Fukushima 33 In 2002 TEPCO admitted to falsifying safety records; (source: wikipedia) • Resulting scandal led to departure of senior TEPCO executives. – And the disclosure of previously unreported problems. • Combined with a fuel leak, the scandal led to the closure of all 17 reactors. Nuclear Reform Plan includes “Policy Statement”: TEPCO is committed to transforming into “an organisation with the world’s highest level of safety awareness, engineering capabilities and risk communication ability in order to prevent a recurrence of a Fukushima-like accident...” Pardon me for thinking this, but surely, surely those in the nuclear power industry should have this as a “given” ... ?
  • 34. Thank You and Questions? Martin Ralph mralph@ifap.asn.au

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