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A human and Organizational Factors Perspective on the Fukushima Nuclear Accident

Abstract : This report examines the Fukushima Dai-ichi nuclear accident using a human and organizational factors framework. It analyzes the crisis at three levels: the frontline operators; the plant as a whole; and the political context including the management team of the electric company and national politicians. By looking at each of these levels as well as the relationships between them, this report describes the way the organizational structures and their accident management procedures contribute to or hinder the resolution of the crisis. The report offers detailed chronologies of the unfolding of the crisis at each of the three active reactors at Fukushima Dai-ichi, at the political level, and at Fukushima Dai-ni. These case descriptions are used as the basis for an analysis drawing on risk and crisis management studies, in particular examining Perrow’s (1999) centralization-decentralization conundrum and Weick’s (1988, 1993, 1995) work on sense-making, among others. The main findings include: 1/ The accident disrupts not only the situation, but also in the ways people go about gathering information on the situation People had to make sense of what happened and find new ways to interpret limited information 2/ Tue interruption of the communication flow between the ERC and MCR can have dramatic consequences. It is important to maintain the communication between the ERC and MCR in all circumstances. 3/ The difficulty of simultaneously supervise crisis room tranches due to its under sizing. A capacity adjustment to the ERC must be made according to the number of reactors involved. 4/ Because of the reluctance to make the decision to test a new possibility in a crisis context, internal coordination is necessary to decide on the implementation of new solutions. Crossfunctional teams can be very useful in coming up with new solutions. 5/ Worker safety policies should be as clear and specific as possible before accidents occur. Where sub-contractors are involved, clear policies on worker safety and degree of commitment are even more important. 6/ Decentralization, even when planned and professed, may be difficult to maintain in practice, particularly as crisis become drawn out.
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Submitted on : Monday, March 29, 2021 - 11:41:32 AM
Last modification on : Wednesday, October 26, 2022 - 8:14:07 AM




Elsa Gisquet, Malka Older. A human and Organizational Factors Perspective on the Fukushima Nuclear Accident. [Research Report] Institut de Radioprotection et de Sûreté Nucléaire. 2015, pp.100. ⟨hal-03184161⟩



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