December 11, 2012


Tell the Whole Truth about the Tragic Accident to Extract Useful Lessons for a Safer Nation

Keywords: Newsletter 

A message from the Chairperson of the Independent Investigation Commission on the Fukushima Daiichi Nuclear Accident
JFS Newsletter No.123 (November 2012)

JFS/A message from the Chairperson of the Independent Investigation Commission on the Fukushima Daiichi Nuclear Accident: Tell the Whole Truth about the Tragic Accident to Extract Useful Lessons for a Safer Nation

In order to investigate the causes and background of the Fukushima Daiichi nuclear accident triggered by the Great East Japan Earthquake on March 11, 2012, four investigative commissions were established by four different entities - Japan's National Diet, the Japanese government's administrative branch, Tokyo Electric Power Company (TEPCO), and a civilian group. Each commission investigated both the causal factors and the crisis response, and submitted their reports.

Independent Investigation Commission on the Fukushima Daiichi Nuclear Accident

The National Diet of Japan Fukushima Nuclear Accident Independent Investigation Commission (archive)

Investigation Committee on the Accident at the Fukushima Nuclear Power Stations of Tokyo Electric Power Company

Release of the Fukushima Nuclear Accidents Investigation Report

The civilian investigative committee was organized under the leadership of six external 'ombudsmen' including prominent scientists, lawyers and energy experts together with about 30 select younger-generation scientists, journalists and lawyers. This "Independent Investigation Commission on the Fukushima Daiichi Nuclear Accident" (hereinafter 'the Commission') engaged in investigative hearings and data analysis. Over the course of six months, the Commission reviewed not only the direct causes of the accident, but also the background and fundamental loopholes from an independent citizens' perspective and released its report on February 28, 2012.

Report by Independent Investigation Commission on the Fukushima Daiichi Nuclear Accident (in Japanese)

This article presents a message, "Tell the Whole Truth about the Tragic Nuclear Accident to Extract Useful Lessons for a Safer Nation," from Koichi Kitazawa, chairperson of the Commission and former chief of the Japan Science and Technology Agency. I hope readers can further share this independent civilian report in the interest of preventing further tragedies of this kind.

Important Features of the Accident at Tokyo Electric Power's Fukushima Daiichi Nuclear Power Plant

A serious nuclear reactor accident is most likely to occur as a result of the loss of coolant water. The most important features of the accident at the Fukushima Daiichi Nuclear Power Plant involved its overcrowded site layout and a proliferation of catastrophic dangers. At the Fukushima Daiichi plant, six nuclear reactors and seven spent fuel pools were positioned in close proximity to one another. Operators at the site, facing a nightmare scenario of unreliable readings from water-level meters, pressure gauges, and other measurement equipment, were forced to turn their attention to increasingly dangerous situations developing simultaneously in several of the reactors and several of the spent fuel pools. With radiation levels increasing as the situation deteriorated in one reactor, explosions in other reactors sent debris flying through the air, while damage to equipment and facilities stymied efforts to address the situation in yet other reactors and spent fuel storage pools - the dangers seemed to multiply at every step.

Our report describes the most serious dangers created by this accident which were not clearly communicated to the public. We learned that top-level government officials were for an extended period gripped with a crippling sense of crisis regarding the possibilities that 1) rising pressure in the No. 2 reactor containment vessel might lead to an explosion and the release of huge quantities of radioactive substances, and 2) that the spent fuel pool in the No. 4 reactor, at the time temporarily out of operation for maintenance, had been directly exposed to the outer air due to the loss of its roof from an indoor hydrogen explosion. Had these situations deteriorated further, it could have meant expansion of the evacuation zone to more than 200 km, affecting as many as 30 million citizens, including many in the Tokyo area. Shunsuke Kondo, Chairman of the Japan Atomic Energy Commission, drew up a simulation and reported it to (then) Prime Minister Naoto Kan as "The Worst Case Scenario."

Sharing information at a time of crisis: Instructions from government agencies to site workers and the sense of elite panic

Heeding seismologists' warnings that the East Japan earthquake could induce another large earthquake in the Tonankai area, the government, already in a high state of crisis, was forced to plunge directly into accident-control management preparations. Prime Minister Kan's abrupt visit to the Fukushima Daiichi plant, his insistence in his speech at TEPCO headquarters that he "refused to permit TEPCO to withdraw" from the nuclear plant, the aerial dumping of water on nuclear reactor buildings using Japan Self Defense Force helicopters, and the government's request, made one and a half months after the accident, that Chubu Electric Power shut down its Hamaoka nuclear plant located in the Tonankai area - all these incidents can only be understood in the context of the great fear shared in the cabinet office that "the country just may not survive" the crisis caused by the over-crowding of its nuclear reactor facilities.

This accident exposed inadequacies in Japan's systems for sharing information. Specifically, there were insufficient transfers of information from the power plant to TEPCO headquarters, to the Nuclear and Industrial Safety Agency (NISA) and the Nuclear Safety Commission (NSC), and to the cabinet office, and this created a climate of mutual paranoia and suspicion. For a government to manage a crisis, it must utilize cutting-edge information technology and create information conduits that are high-volume and shared. In addition, we learned of instances in which information was concealed due to "elite panic," in which officials at each level of government become fearful of inciting panic among the general public and failed to pass on critical pieces of information either to upper or lower levels. Examples include the failure to disclose to the public data on radioactive contamination zones predicted by SPEEDI (System for Prediction of Environmental Emergency Dose Information, a "computer-based decision support system" operated by the Nuclear Safety Division of the Ministry of Education, Culture, Sports, Science and Technology), as well as the decision not to inform the public of the "worst-case scenario" mentioned above. In the face of grave danger, how should information be disclosed to the public? Throughout the crisis, the government and TEPCO were continually challenged by the questions; "Who has the right to the information? Does the public have a right to know, or is it acceptable for public officers at various levels to decide among themselves to keep information hidden?" What Japan needs now is to do the hard work of constructing an organizational infrastructure to allow unfettered sharing of information in times of crisis. It is now our job to start designing systems in which information can be shared smoothly even in a period of crisis via multiple channels among various levels of government, and with foreign governments as well.

Facade of formalism pervades Japan's nuclear safety assurance framework

During the course of this investigation, it became clear that Japan's framework for ensuring nuclear safety has lost its substance in spite of a brilliant facade; it is a "paper tiger" organizational mechanism. Nothing is more emblematic of this phenomenon than the widespread persistence of the "myth of absolute safety." The myth of safety is said to have been constructed to convince local populations to accept nuclear plant construction, but as time passed, nuclear power promoters themselves started to find themselves trapped in their own myth of safety, creating a culture within which it became taboo to suggest that safety could even be improved. Both electric power companies and manufacturers of nuclear reactors somehow got it into their heads that improving the safety of something that is already perfectly safe is a logical contradiction and thus they became incapable of conceptualizing the notion of improving safety, either by enhancing existing procedures or instituting new ones. The phrase "safety improvement" was removed from specification documents submitted to power companies from manufacturers, and the idea of modifying design specifications "for safety reasons" became next to impossible.

An excellent illustration of the culture pervading the nuclear power community is offered by the "policy philosophy" of the Nuclear Safety Commission, which seems to embody the notion that the total loss of AC power for an extended length of time is a contingency that need not be contemplated, because power lines will be restored or emergency AC generators will come on line. How could the Nuclear Safety Commission, whose very mission is to ensure the highest possible safety levels, have designed policies built atop such fallacious reasoning? Because of this ill-advised policy, power companies became reluctant to prepare for serious accidents. This phenomenon can only be interpreted as the Nuclear Safety Commission pandering to the power companies, helping them reduce their economic burden by sacrificing safety. "There is no question that, in those days, TEPCO had a strong voice in Nuclear Safety Commission," says one high-level government official who formerly promoted nuclear power. "Of course, once such policies like this were in place, it became essentially impossible for anybody to say 'this is wrong!' or to attempt to make any amendments."

In the U.S.A. and Europe, after the 1979 accident at Three Mile Island and the multiple simultaneous terrorist attacks of 11 September 2001, governments adopted various protection measures to deal with potentially serious nuclear accidents, such as new types of sensors and improved vent valves. However, the Japanese government and Japanese power companies failed to introduce most of these new measures and thus Japan was without adequate protection against serious accident. The fact that our nation, which faces probabilities of massive earthquakes several tens of times higher than the world average, would take such an attitude toward the incorporation of new safety measures can only be considered a source of great shame for Japan before the international community.

In the course of this investigation, we spoke with former government officials experienced in nuclear safety, as well as former members of TEPCO's management team, who all used different words to say essentially the same thing. "There was clearly an awareness that safety precautions were insufficient. However, there was nothing that I or any other individual could do to make a difference; it would be like trying to dam a flood with a toothpick." With the "myth of safety" having built up gradually over time and crowding out all other points of view, all interviewees described the same general attitude: People could sense which way the wind was blowing. Nobody dared say anything that would cause trouble to the organization to which he belonged. Instead, people just went with the flow. This kind of attitude might be interpreted as a reflection of certain unique attributes of Japanese culture. But if Japan is a society in which "going with the flow" has become a fundamental survival skill, this also means it is a society that has proven itself incapable of safely operating complex, high-risk, large-scale technologies such as nuclear power generation.

The nuclear power community, "the nuclear village"

A vivid portrait of the relationship between the Ministry of Economy, Trade and Industry (METI), which regulates the nuclear power industry, and the businesses they regulate was painted by a former high-level METI official during one of our hearings.

"You see, TEPCO is a company that rejects flat-out any requests by independent power companies for permission to use TEPCO's transmission lines to transmit their power," this former official explained. "They use government regulations as an excuse for these rejections, saying, 'Well, we don't have any problems with it on our own part, but unfortunately it can't be done because of government regulations,' thereby maintaining a monopolistic stranglehold over the system. In our guidance and regulations we were basically spoon-feeding the power companies. In the mid-90s, we revised th regulations. It was perceived that this was done in order to improve the situation with the Agency for Natural Resources and Energy, which was then controlled by TEPCO.... We were supposed to be regulating them, but in fact they were just using us as a tool. I'm not saying that the Nuclear and Industrial Safety Agency can't stand up to TEPCO, but...."

By their nature, nuclear safety regulations must be able to exist in confrontation with nuclear power promoters. Without fundamental legislative and organizational reforms that destroy the excessively comfortable relationship that has developed between the regulation and promotion sides, it will be nearly impossible to ensure the safety of nuclear power.

In addition, our investigation revealed that this cozy "nuclear power village" harbors many different types of structural collusion. Politicians from both majority and opposition parties receive contributions either from electric power company executives or labor unions; mass media companies receive massive advertising revenue from electric power companies; nuclear engineering researchers in academia receive huge research grants from electric power companies; former government administrative officials pass through a revolving door into employment at electric power companies or organizations working on nuclear power issues; electric power companies dispatch employees to government agencies or organizations working on nuclear power issues; the national government provides assistance to cultural institutions and educational organizations designed to support nuclear-power-friendly education for children; regional governments receive subsidies from the national government for providing sites for nuclear facilities; power companies donate money to regional governments for cultural facilities and other infrastructure projects; and thus, through these and other means, a full-scale "village" has been knit together. This community, the "nuclear power village," may be thought of as a giant profit-sharing organization with a well-honed ability to sense which way the wind is blowing and make its moves with ponderous inertia. Thus it is clear that, no matter how hard we try to establish regulatory bodies or safety assurance committees within this community, before long they will simply be absorbed into the familiar mutual back-scratching patterns of business as usual. Fundamental reforms are needed in legislation, operational systems, and organizational structures, but even these alone will not suffice; an even more fundamental organizational reformation is needed to bring securely into being a pervasive spirit of "civilian control." That is, we need a system that can attract a continuous stream of people from outside the village to serve in positions of importance within it.

Building a safer Japan

Of the approximately 20,000 people who perished in the Tohoku earthquake disaster, 93% are estimated to have died from the tsunami. To date, the nuclear accident has not been directly responsible for any deaths, but today (a full year later) over 100,000 people continue to live as refugees from radioactive contamination. On top of this, many hundreds of thousands of people lead daily lives of anxiety over the unknown effects, both immediate and far into the future, of radioactive contamination.

News of the Tohoku earthquake disaster and its aftermath was broadcast around the globe, and so the plight of disaster refugees has gained attention not only within Japan but in the wider world. A deep spirit of community binds people who have suffered together and motivates citizens to care tirelessly for one another without succumbing to panic, and it is this that gives us hope for future rebirth and recovery. From a great many foreign countries, we have received heartwarming words of encouragement, massive financial assistance and other assets to assist in our recovery, as well as the support of emergency rescue teams. We, the members of this investigation commission, would like to take the opportunity of publishing our report to extend our deepest gratitude to the countries around the world that have rushed to assist our nation in its time of need. The world's sympathies and encouragement will linger in the hearts of the Japanese people and lend invaluable spiritual sustenance to empower recovery in the disaster area.

Nonetheless, the accident at TEPCO's Fukushima Daiichi nuclear power plants released a large quantity of radioactive substances that have contaminated the global atmosphere and international waters. The Japanese government, though admittedly challenged by a crisis involving multiple simultaneous dangers, failed to promptly notify other countries of these radiation leaks. For this, on behalf of all Japanese people, we extend our apologies to the world.

This report documents the findings of a working group of some 30 people, both young and mid-career, including natural scientists, engineers, social scientists, businesspeople, lawyers, and journalists, who researched the subject by gathering resources and conducting investigative hearings to record the testimony of relevant individuals. The committee composed of myself and five other senior members with various backgrounds was convened to act as an external ombudsman with the responsibility of summarizing the conclusions of the working group in the form of this report, which we hope will be translated into English and shared with the world by early 2013. Needless to say, a civilian accident investigation committee is entirely devoid of official authority. However, the young people in the working group worked passionately to communicate their message to politicians and bureaucrats, officials of regional governments, persons involved in the Fukushima accident, and others in positions of authority. As a result, these people eventually gave us detailed statements. We extend our deep gratitude to all the people who agreed to grant us an interview. In conclusion, by clarifying more of the truth underlying the tragic saga of the multiple catastrophic accidents at the Fukushima Daiichi Nuclear Power Plant in this report, we hope to have taken a small step toward extracting useful lessons for Japan and the world that will help ensure a better future for our children.

Koichi Kitazawa
Chairperson, Independent Investigation Commission on the Fukushima Nuclear Accident
Former President of Japan Science and Technology Agency