RETROSPECTIVE REVIEW OF ORGANIZATIONAL AND CULTURAL FACTORS PRIOR TO THE

FUKUSHIMA NUCLEAR ACCIDENT 2.1. Before the Great East Japan Earthquake

The business environment for Japan’s electric power companies has changed significantly over the past decade. TEPCO was significantly affected financially. The capacity factor declined after the announcement of falsified voluntary inspection records for reactor internal structures and other components in 2002 (the TEPCO scandal) and after the Niigata-Chuetsu-Oki Earthquake in 2007.

In these circumstances, the Nuclear Power Division believed that safety had been established after several severe accident countermeasures were implemented. In order to improve TEPCO’s financial situation, the TEPCO Nuclear Division recognized improvement in capacity factor as an important business challenge. In a risk map used for determining operational priorities, the avoidance of long term shutdown periods was configured as one axis for making such assessments. For example, the discovery of a crack in the shroud would require a long term shutdown, so, despite the high cost, such issues were focused on, even though they did not contribute much to improving safety. On the other hand, more effective measures for enhancing safety, such as considering how to diversify or arrange power supply facilities as well as sealing important pump and battery rooms against water intrusion, did not to contribute to improve capacity factor and therefore were not taken seriously nor implemented.

In response to the TEPCO scandal, a variety of improvements focused on quality aspects. For example, the introduction of the Quality Management Systems (QMS) was one facet of its response to the 2002 scandal. QMS was employed to establish processes for rigorously managing non-conformance events. However, activities focusing directly on safety, such as engaging in reviews that go back and reconsider the design basis were not performed in any great detail. The actions taken proved to be insufficient to foster the strong safety consciousness necessary for a nuclear operator.

From organizational and cultural perspectives, the fact that the learning attitude within the organization was not sufficient might have caused the Fukushima nuclear accident. From knowledge of the incident in 1999 in which a flood knocked out the power supply at France’s Le Blayais Nuclear Power Plant [2] and from that of the inundated seawater pumps at India’s Madras Atomic Power Station following the Sumatra Island earthquake, we should have considered the impact on a plant that arises from the total loss of its power supply. If we had learned from the variety of documentation that was available

around the world in our daily operations, we would have been able to obtain information about B5b, an anti-terrorism countermeasure adopted in the USA.

All of these things are clear now in hindsight. We believe a sort of self-satisfying complacency existed, as part of our organizational culture, which became an underlying factor preventing us from carrying out sufficient safety preparations prior to the Fukushima nuclear accident.

2.2. Nuclear renaissance activities

The nuclear renaissance activities were initiated after the 2002 TEPCO scandal for the purpose of extending measures to prevent such a recurrence and turning TEPCO into a world class nuclear operator. These activities were advanced principally through the Leadership Development Exchange (LDE) and Operation Process Improvement Activities (peer group activities).

LDE was a two week programme designed to alter the way participants think. They were able to gain an understanding of the best practices employed in the USA as they learned communication skills and problem solving techniques.

Over six years, nearly 600 managers and team leaders were sent to the USA.

Participants gave these training sessions high marks and the programme sufficiently achieved its aim of jolting participants in a positive way and channelling them towards addressing improvements. On the other hand, nuclear top management in place at the time provided insufficient sponsorship for the programme, and the operational reforms that would use the skills gained were not sufficiently instituted.

The purpose behind the peer activities was to analyse and improve maintenance, operations and other processes at our three power stations. It also encouraged sharing practices and raising their quality to world class levels.

As a result of such activities, a certain level of success was achieved, such as the revision of processes to prepare for refuelling outages to make these more efficient and systematic. However, against a backdrop of power stations persistently adhering to their own processes, much time and effort were spent on achieving consistency across those organizations. In addition, it was observed that ‘approvals necessary for implementing improvement plans were not readily granted’, that ‘managers who approved plans just left the implementation to review groups’ and that ‘nuclear top management ceased to be committed midway through such projects’. Nuclear senior managers did not sufficiently share the belief that improvements could be promoted throughout the entire organization in a unified, efficient and effective manner by standardizing the processes and tools supporting these processes. Consequently, nuclear senior managers were not engaged in continuous and integrated monitoring and follow-up of these activities and they gradually waned. Middle management, team leaders and

senior operators, who were the backbone of these activities, began to question the seriousness of top management.

2.3. Activities to foster nuclear safety culture

A WANO corporate peer review, conducted in September 2008, indicated that there is room for improving comprehension and acceptance of a safety culture throughout the entire organization. TEPCO then established ‘TEPCO’s Basic Principles for Safety Culture (Seven Safety Culture Principles)’, using WANO’s Eight Principles for a Strong Nuclear Safety Culture as a guide. Assessments of safety activities at power stations, in accordance with the Seven Safety Culture Principles, were conducted and the results were reported to the President annually.

External safety inspectors also annually conducted ‘assessments of activities for fostering a safety culture’.

TEPCO’s activities to promote greater comprehension and acceptance of safety culture, after the establishment of the Seven Safety Culture Principles, were limited to superficial pursuits such as explaining language, reciting the said principles and attending annual lectures delivered by external instructors. Over that period of time, not only did the previously mentioned TEPCO scandal occur, but a variety of problems arose leading to shutdowns. Facility modifications that are likely to have affected nuclear safety were implemented. Industrial safety events continued to occur and even sabotage was carried out by workers. The frequency of occurrence and reporting of these and other events indicated a deteriorating safety culture. However, self-assessments and safety inspections before the Fukushima nuclear accident produced results showing ‘no signs of degradation of safety culture’. No drastic or thorough actions were therefore carried out to improve the safety culture.

A significant factor in creating such a situation was that the organization, and particularly its leaders lacked a willingness to face the status quo.

2.4. Summary of organizational factors reconsidered

The Nuclear Reform Special Task Force reviewed the organizational factors underlying TEPCO’s emergency response at the time of the Fukushima accident.

These are summarized below.

There was a perception that an acceptable level of nuclear safety had already been sufficiently achieved, and that the organization was going to be reorganized by simply training communication skills and problem solving techniques. There was no keen awareness that the TEPCO scandal was a sign of a deteriorating safety culture, making organizational efforts made to improve safety awareness insufficient.

The former nuclear top management should have taken the initiative to enhance safety awareness throughout the organization in a committed manner.

However, no specific policies were adopted to change their own awareness or the way in which work was performed. They believed that causes were weaknesses in first-line supervisors and problems in site organization.

Although unclear organizational authority and responsibility were revealed during the emergency, such a lack of clarity regarding authority and responsibility was also observed even during normal operation.

This could all be summarized in terms of a belief that safety had already been established and that capacity and other such indices were perceived to be the important management issues. This resulted in an increased dependence on manufacturers for engineering and contractors for field work. This, in turn, lowered TEPCO’s engineering and technical capabilities and led to insufficient preparation for accidents. Moreover, this situation also involved insufficient communication with local stakeholders.

An illustrative structure is presented in Fig. 1 in terms of a ‘negative spiral’.

Because this negative spiral was firmly rooted in the organization, such problems were very difficult to resolved. measures necessity if it is safe enough

FIG. 1. The negative spiral.

3. NUCLEAR SAFETY REFORM PLAN AND ITS