1) The Fukushima nuclear disaster was caused by an earthquake and tsunami in March 2011 that cut power to the plant and disabled the backup generators, causing a meltdown in three reactors. 2) While initially a natural disaster, socio-technical failures like lack of oversight, poor planning, failure to address warnings, and prioritizing profits over safety turned it into a man-made catastrophe according to various accident theories. 3) The disaster highlights the need for independent regulation, redundant safety systems, and rethinking nuclear power given the risks of technological failures during natural disasters.

1. Fukushima: The Perfect Storm for Disaster
Nicole Murray
PA 583 Technology, Accidents and Organizations
October 10, 2013

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The short and simple answer to why the Fukushima-Daiichi nuclear power
plant experienced a meltdown is they experienced a power loss. No disaster of this
magnitude has a simple reason, and Fukushima is no different. In the Lemony
Snicket movie, A Series of Unfortunate Events, a simple and normal act- in the movie
an earthquake caused a house to tilt- set off a chain reaction of strange and
compounding problems which led to disaster. What seems like a silly part of a movie
is hauntingly familiar to what happened in Japan on March 11, 2011. The fatal mix
of technological, organizational and social failures will be diagramed and compared
to Socio-technical systems failure, James Reason’s Organizational Accident Theory
and Barry Turner’s Disaster Incubation Theory.
In order to understand the various dynamics that led to the Fukushima
nuclear disaster, you first need to understand how nuclear power came into
existence. Four broad domains of technology include production systems,
transportation systems, communications systems, and more recently biotechnology
(Sterry & Hendricks 1999). Nuclear power would be a production system. In
Prospects for Nuclear Power, Lucas W. Davis delves into the birth and decline of
nuclear power. In 2009, natural gas prices plummeted. This resulted in a drastic
decline in demand for nuclear power, which up until that point was a cheaper means
of producing electricity. Up until this point, electricity was slightly more cost
effective when it came from nuclear power, opposed to natural gas. Advances in

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fracking and other technology allowed easier access to natural gas, which led to its
decline in price.
Cost efficiency is a tricky concept. The primary costs of a nuclear power plant
include the vast sum of money to construct a proper site and pay the various
specialized engineers. Davis (2012) brings light to the secondary costs of nuclear
power, such as relocation costs and psychological and physical damage incurred
when a nuclear power plant experiences malfunction. These peripheral costs
combined with the primary costs make nuclear power less cost-effective than
natural gas. However, in 1957 the Prince-Anderson Act put a cap on the accident
liability nuclear plant operators would have to pay. Currently, this is set at around
twelve billion dollars- which is well below what a Fukushima type accident would
cost.
Technological disasters and natural disasters are the same in that they both
affect the community in physical, social, and psychological ways. However, the
effects vary between these two different disaster types. In the book Minding The
Machines: Preventing Technological Disasters by William M. Evan and Mark Manion,
these two types of disasters are simplified into “Acts of God” and “Acts of Man.” The
first type is characterizes as unpredictable and unpreventable, whereas the second
type is characterized as predictable and preventable.
Whereas natural disasters tend to bring a community together, to work to
solve the despair that has affected everyone equally, a technological disaster seems

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to first evoke emotions of blame casting in those affected. Instead of uniting, victims
want to know why and how such a travesty could have occurred and why the CEO or
company did not prevent such a thing from occurring.
In Facing The Unexpected: Factors Influencing Disaster Preparedness and
Response, the authors point out that disasters do not affect everyone equally. They
state, “… everyday patterns of social inequity- such as unequal access to housing,
information, services, and political power- carry over into post-disaster settings and
are reflected in victims’ experiences.” While a hurricane does not discriminate
which house it destroys, or a mine explosion does not differentiate which workers it
kills, socio-economic factors do play a role in fatalities. Housing structures are more
secure and solid, the more money it costs to build and live in it. So the poorer the
neighborhood, the more poorly built the structures, the more damage such buildings
incur. Additionally, the less money citizens have, the lower their insurance coverage
is. Also, the working class is usually more affected by technological disasters, as it is
the lower end grunt work, such as miners, whose job puts their life in danger, should
safety codes not be followed, and disasters happen.
March 11, 2011 saw a fatal mating of natural and technological disaster that
birthed the Fukushima Nuclear Disaster in Japan. Evan and Manion (2002) describe
a difference in natural and technological disasters. The first is often thought of as
“god-made”, while the latter is often thought of as “man-made”. Another way to
differentiate are the concepts of predictable and preventable, opposed to

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unpredictable and unpreventable. Japan experienced both sides of the spectrum that
fatal day in March. Tohoku, a magnitude 9 earthquake and tsunami, overloaded 561
square kilometers of coastline and up to five kilometers inland (Bird & Grossman
2011). The devastation created an extended period of time with loss of power to the
Fukushima-Daiichi nuclear power plant. The nuclear power plant, run by Tokyo
Electric Power Company (TEPCO), unable to cool the reactors, experienced a
nuclear meltdown in three of its six reactors.
Harutoshi Funabashi sequenced the events in the article Why the Fukushima
Nuclear Disaster is a Man-made Calamity (2012).
1) The earthquake destroyed a towerwhich supported power lines.
Consequently, the outside electricity supply for the nuclear
power plant was shut down.
2) The emergency power supply did not function because diesel
generators had been built under the turbine buildings where the
tsunami struck.
3) Circulation of cooling water stopped and the remaining water
vaporized due to the ensuing heat.
4) Loss of water was caused partly because of the destruction of
pipes by the earthquake.
5) The level of water in the reactor pressure vessel decreased.
6) Nuclear fuel was completely uncoveredand thus began to melt
down.
7) Hydrogen was produced in the reactorpressure vessel through a
chemical reaction between water and zirconium coveringthe
pipes. This split into the reactor container and also into the
building housing the reactors.
8) Successive hydrogen explosions occurred (Unit1 on 12 March,
Unit 3 on 14 March, Unit 4 on 15 March). These destroyed
buildings housing the reactors and dispersed radioactive
substances.
9) Water injection was necessary and executed. However,this then
increased the leakage of polluted cooling water.
10) Radioactive substances spread over a vast amount of land and
through the atmosphere, as well as spreading into the Pacific
Ocean.

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Power was lost for an extended period of time, causing a chain of events that
led to a nuclear meltdown. Michael Levi summed it up nicely when he stated, “the
lesson is not just that there’s a particular failure mode associated with earthquakes.
It’s that things happen that you don’t predict when you have very complex systems,
and you need to be prepared…(32)”. It is impossible to predict every sequence of
what could go wrong. However, leaders should anticipate the outcomes of the worst
possible scenario. In the Fukushima-Daiichi nuclear power plant meltdown, they
failed to do so.
Fukushima obtained a maximum level 7 rating on the sliding scale of nuclear
disasters. Some say it is worse than the 1986 Chernobyl nuclear accident. The
nuclear output is 72,000 times worse than the Hiroshima bombing as Fukushima
has released 15,000 terabecquerels of Cesium. Cesium is known to cause cancer and
the amount let out is 168 times worse than the Cesium released by the Hiroshima
bombing of 1945 (McNeill 2011). Radioactive water has been leaking into the Pacific
Ocean ever since the accident. Could this magnitude of safety control measures have
been predicted? Some would argue, “Yes”.
There are many disaster theories out there. High Reliable Theory basically
states that high-risk systems are successful because safety is a number one priority.
The hiring of personnel involves high accountability and a common understanding
that safety is key. Mistakes can easily be reported and personal relationships
between coworkers is cooperative versus competitive. Human operators are

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motivated to prevent failure.
Another key factor is redundancy and organizational learning.
Redundancy helps organizational learning while decentralization of
authority is adopted. The chapter, The Origins of Accidents by Sagan (1993),
describes a situation on an airline carrier, where different levels of authority all
have the ability to cancel the takeoff of an airplane. The passage describes the
various levels of positions and states that a common deck worker, if notices a safety
hazard upon inspection, has the ability to cancel the flight until this safety concern is
addressed. Bunn and Heinonen (2011) analyzed the Fukushima disaster and
suggested the need for redundant instrumentation and back up controls in case the
reactor control room stops functioning, as happened in Fukushima.
The theories most suiting to the Fukushima-Daiichi Nuclear Disaster however,
are the Socio-Technical Systems Theories. These theories focus on the relationship
between sociological factors of the humans operating the machines, and the
machines themselves. Acknowledging there are multiples of factors, both human
and technological, does not make it impossible to prepare for malfunctions. Two
theories in particular, Barry Turner’s Disaster Incubation Theory and James
Reason’s Organizational Accident Theory will be applied to the Fukushima Nuclear
Disaster.
Barry Turner’s Disaster Incubation Theory suggests that there are early
indicators to the possibility of a problem. Principle characteristics of Turner’s

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Incubation Theory are failure of foresight, rigidities in perception and belief in
organizational settings, a decoy problem, organizational exclusivity, information
noise and difficulties, minimizing threat of danger and failure to comply with old
regulations.
Decoys, a phenomena discussed in Barry A. Turner’s The Organizational and
Interorganizational Development of Disasters (1976), simply implies those parties
involved in a situation being distracted and thrown off by another safety issue,
thereby ignoring or not realizing another unrelated, but equally as dangerous
situation. Failure of foresight and overconfidence are other phenomena of Turner’s
Disaster Incubation Theory.
Overconfidence and “failure of foresight (1976)” aid in ignoring these early
warnings. Japan experienced an earthquake in January 1995. This alerted citizens to
the possible dangers to a nuclear power plant. These raised concerns however, were
ignored by nuclear power supporters. Funabashi (2012) stated, “…they were unable
to foresee the severe damage that could be brought by earthquake and tsunami
(70).” Funabashi further details the many warnings that were ignored, even though
the whistle blowers were specialists, engineers and members of local and national
assemblies.
James Reason wrote Managing the Risks of Organizational Accidents in 1997
and tells of the risks earthquakes present to draining pools of radioactive waste

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(170). A full fourteen years prior to Fukushima! Obviously, a failure of foresight was
a major factor in the Fukushima Nuclear Disaster of 2011.
James Reason has his own Socio-technical systems theory called
Organizational Accident Theory. His theory attributes failures to the tension
between profitable production and safe practices, as well as latent and underlying
conditions that have always been present but only surface in times of disaster. In
Why the Fukushima Nuclear Disaster is a Man-made Calamity, multiple “social
safeguards” were blamed for the technological failure. Economic profit was put
before safety. The article also pointed out latent conditions, which hindered a rapid
response to prevent further escalation of the incident, once the initial damage was
done.
Do the risks outweigh the benefits? How Did Fukushima-Daiichi Core
Meltdown Change the Probability of Nuclear Accidents? state, “critics claim that
nuclear power entails a latent threat to society and we are very likely to witness an
accident in the near future (1).” If nuclear accidents are almost inevitable, why is
nuclear power still an option? The answer is a convoluted one.
The relationship between proponents of nuclear power, opponents of nuclear
power and the regulating agencies can be muddled. In Japan, regulators lack
independence. The regulation and promotion of nuclear power is not separate
(Funabashi 2012). The Prime Minister approved the Fukushima-Daiichi plant based

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on expert knowledge of the Nuclear Commission who confirmed the safety of the
design. After the accident, they recanted this decision and stated they
underestimated the real danger.
Bunn and Heinonen (2011) demand tighter national and international
regulations of safety standards. However, the weak degree of autonomy of
regulators from the nuclear industry unveils organizational weaknesses.
Furthermore, the inability to cool nuclear reactors when a prolonged loss of power
is experienced must be fixed.
More social failures include social decision-making.
Beaurocratic sectionalism posed another man-made obstacle
during cleanup: information as well as responsibility for
environmental monitoring and cleanup is divided between various
ministries and branch of local government, which increases the
likelihood that, in the end, none will fulfill their shared responsibility.
(Bird & Grossman 2011, A300)
Shunning of responsibility is only one aspect of the social failures involved in
the Fukushima nuclear disaster. Misinformation is another aspect. The economic
dominance of nuclear power guarantees a heightened political power, and with this
power they are able to manipulate which information is passed along to the decision
makers. Power begets power. The first plant design of Fukushima-Daiichi six
reactors was made in 1975. Later, GE engineers fount faults in the design, but

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nothing was done to fix the problem. Those deciding to approve designs for further
reactors were unaware of this finding.
What about the regulation guides in place at the time of the accident? Are the
industry leaders at fault for not obeying the guidelines? Yes and No. The regulatory
guides do not account for catastrophic events, such as those on March 11, 2011.
There was a seawall in place, however it was too low for a tsunami of the size on
March 22, 2011. The costal area of Fukushima is prone to tsunamis and therefore
was poor planning in placing a nuclear reactor site there. Additionally, there is an
old adage that says not to place all your eggs in one basket. While not every nuclear
reactor site in Japan was located in Fukushima, a total of six were. Again, poor
planning was at stake here.
The Fukushima nuclear accident on March 11, 2011 may have been started
with the natural disaster of the earthquake and tsunami. But socio-technical factors
allowed the accident to have a breeding ground. Latent threats, failure of foresight,
inability of the regulating agencies to be independent of bureaucracy, poor site
planning and many other variables were to blame in this disaster. It is the authors
opinion that nuclear power is too dangerous in its failure possibilities and should be
slowly eradicated. In order for this to happen, we need stronger legislation,
reduction in energy consumption and stronger research in renewable energy
sources.

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Davis, Lucas W. 2012. Prospects for Nuclear Power. Journal of Economic Perspectives.
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Evan, William M., and Mark Manion. 2002. Minding the machines: Preventing
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McNeill, David. 2011. Why The Fukushima Disaster is Worse than Chernobyl. The
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Reason, James. 1997. Managing the Risks of Organizational Accidents. Burlington, VT:
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