Accident in Japan: -- Lack of Safety Culture?

["J. J. Rozental" <josrozen@netmedia.net.il>]

A nation that has built a reputation for quality in high-tech manufacturing
should not have such workmanship errors, Prime Minister  Keizo Obuchi said.
The head of the Science and Technology     Agency warned of the "moral
disintegration among engineers" in Japan. Even officials of the nuclear
industry said there are morale problems among workers and mismanagement in
companies. These statements  show in Japan lack of Safety Culture.  The
degree only after a complete program for evaluation.
This accident of coarse will draw the attention of all responsible parties
in developing and developed countries to review if protection and safety are
in conformity with the relevant requirements of National and International
Standards.  This should be done at  any particular facility, component of
the nuclear fuel cycle, as well  another installation where radioactive
materials are been used. The objective is  to identify any latent weakness
in the installation and to implement corrective actions to eliminate the
latent weaknesses as well as to implement corrective actions to prevent
recurrence of the latent weakness.
I am looking into this accident considering two basic IAEA documents and
Safety Series that contain reported consequences and lessons learned due
Safety problems, direct causes and root causes. Basic Goal: to  write a
paper on Responsible Parties and Safety Culture.

The two basic documents are:

a) The Safety of Nuclear Installations, IAEA Safety Series 110, 1993
b) Basic Safety Standards, IAEA Safety Series 115, 1996

For  my understanding , considering  topics from the press (some topics,
bellow) the responsible parties in the Japan  Accident were:

a) Regulatory Authority
b) Licensee (Organization)
c) Workers
d) Radiation Safety Officer
e) Radiation Protection Officer

Only after the investigation of  circumstances, it will possible to define
the level of responsibility and if any other party also will be involved. 

TOPIC TO DISCUSS

1 - The accident happened when workers  put too much uranium -- 35 pounds
instead of about 5.3 pounds; 

2 -  Makoto Morita, an executive with JCO Co., which operates the plant,
said that the workers manually bypassed part of the required procedure that
would have prevented them from using too much  uranium. -- "We have no words
to express our  apologies". "We cannot escape our responsibility"

3 - "The situation is one our country has never experienced", a government
spokesperson said;

4 -  Arjun Makhijani, president of the Institute for Energy and
Environmental Research in Takoma Park, which studies nuclear problems
worldwide, called it a "very unusual accident" at a plant that is "badly
managed" and has a recent history of radiation exposure problems.

5 - "Our priority now is look into the cause of this  very unfortunate
accident,"  Numata continued., "We have learned that our fail-safe mechanism
sometimes doesn't work --  perhaps  due  to the fallibility of human beings
-- but we are  seriously looking into the causes now" -    
Sadaaki Numata is a spokesman for the Japanese Foreign Ministry.

6  - The Japanese government  admitted that it had moved too slowly to
respond to the incident. It did not hold its first emergency meeting until
10 hours after the incident occurred.

7 - "We  lacked a more serious understanding of the situation of the
accident", said Chief Cabinet Secretary Hiromu Nonaka

8 -  Numata blamed the government's slowness to respond, in part.  on poor
communication between the plant operators and the government -- "There may
have been a series of unfortunate events taking place" , he said. "This
particular accident took place in a plant owned by a private enterprise, and
the communication channel between this private plant and the government
facility may not have worked as it should have. But once we learned the
seriousness of this accident, we engaged in a very intensive effort to
prevent the worst from happening"

9 - "This is what always happens in Japan -- they wait  for an accident to
happen before doing anything", said one nuclear safety expert on NHK television.

10 -  "You can't just blame this accident on workers. There are much more
fundamental problems that must be addressed."

11 - For at least  the past two years , the uranium processing plant was the
site of Japan's worst nuclear accident  had been using an illegal procedure
to handle the dangerous material because   it was faster , an official  of
the company operating the plant said today. - (October 3)

12 - Workers were following a company manual when they poured the uranium
mixture from a bucket into a settling tank on Thursday, the official said.
But this time the head of the three-man crew  instructed his colleagues to
use a 35-pound capacity tank instead of a smaller one.  As a result, the men
put   enough uranium together  to set off a chain reaction  that could not
be stopped until 18 hours later.    

13 - If they had used the government-approved process, the material would
have passed through a measuring cylinder that would have limited the amount
to well bellow the danger level;

14 - "From at least two years ago, we had an internal manual which we did
not present  to the government and which called for using buckets," said a
JCO Co. official in Tokaimura, who asked not to be quoted by name.  "We knew
the practice was illegal but it's faster."

15 - The workers were involved in processing 126 pounds of uranium for use
in an experimental breeder reactor program. The process was used
occasionally; two of the workers were inexperienced, but crew   leader
Yutaka Yokokawa, 54, had done this work before, according to Yutake Tatsuta,
another company official.


16 - From his hospital bed, the supervisor  admitted that a process had been
skipped," Tatsuta said.

17 - Among the unanswered questions is why the Tokio-based JCO Co. had no
contingency plans   to deal with an accident. In a document given to
government regulators in 1983, the company maintained that "critical fission
chain reactions could not occur" at the plant, according to the Japanese
daily Yomiuri Shmbun

18 - Such assertions apparently were accepted by the government's Science
and Technology Agency, which licensed the plants and required minimal
safeguards, all on the assumptions that uranium would not be placed together
in quantities sufficient for a fission reaction.

19 - Chief cabinet secretary Hiromu Nonaka called the failures that led to
the accident "unthinkable" , and declared that "we must examine how nuclear
facilities are being managed"

20 - Kazuo Sato, chairman of the Nuclear Safety Commission said on Sunday
that the Commission would look into whether there had been lax supervision
by the central government

J. J. Rozental
josrozen@netmedia.net.il
Israel
jjrozental

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