RE: Accident in Japan: -- Lack of Safety Culture?

[Bob Flood <bflood@SLAC.Stanford.EDU>]

At 12:25 PM 10/7/1999 -0500, you wrote:
>
>Although it is not clear WHY the company believed (or at least SAID they 
>believed) that "critical fission chain reactions could not occur", the fact
>that this mindset existed is certainly one of the key root causes of this
>tragic accident.

I couldn't agree more. A fine example of the mindset at JCO can be found in
the way the radiation monitors at the plant proved to be useless in the
emergency - the set points were so low that literally all onsite alarms
went off simultaneously, making it impossible to locate the problem from
alarm data. This was a major factor in the slow onsite response to the
accident.

I find it incomprehensible that a facility designed to handle fissile
material in large quantities would not have any plans to deal with a
criticality event, or even monitors capable of detecting one! But, it would
appear that their regulator didn't require such preparaedness, either.

I also believe that the Japanese regulatory agency failed in its duty. JCO
had a regulator-approved procedure for mixing the material safely, but they
developed and implemented a revision without seeking regulator approval
(willful misconduct, it seems), used the unapproved procedure for a period
of a few years, and then deviated from the unapproved procedure, resulting
in the accident. Why couldn't the regulator have found this deviation from
the approved procedure? Even a document-only audit would have identified
the unapproved procedure, and observation of in-plant work would have found
even more differences. So, while JCO can be faulted for not being agressive
about safety, the same can be said of their regulator.

===================================
Bob Flood
Dosimetry Group Leader
Stanford Linear Accelerator Center
(650) 926-3793
bflood@slac.stanford.edu
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