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Sun, 11 Mar 2012 22:40:20 -0400
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Fukushima In Review: A Complex Disaster, A Disastrous 
Response
Yoichi Funabashi and Kay Kitazawa
Bulletin of the Atomic Scientists
March 1, 2012
http://bos.sagepub.com/content/68/2/9.full 

	Abstract

	On March 11, 2011, an earthquake and tsunami
	crippled the Fukushima Daiichi Nuclear Power
	Station. The emerging crisis at the plant was
	complex, and, to make matters worse, it was
	exacerbated by communication gaps between the
	government and the nuclear industry. An
	independent investigation panel, established by
	the Rebuild Japan Initiative Foundation,
	reviewed how the government, the Tokyo Electric
	Power Company (Tepco), and other relevant actors
	responded. In this article, the panel's program
	director writes about their findings and how
	these players were thoroughly unprepared on
	almost every level for the cascading nuclear
	disaster. This lack of preparation was caused,
	in part, by a public myth of "absolute safety"
	that nuclear power proponents had nurtured over
	decades and was aggravated by dysfunction within
	and between government agencies and Tepco,
	particularly in regard to political leadership
	and crisis management. The investigation also
	found that the tsunami that began the nuclear
	disaster could and should have been anticipated
	and that ambiguity about the roles of public and
	private institutions in such a crisis was a
	factor in the poor response at Fukushima.


The 9.0-magnitude earthquake on March 11, 2011, and the
ensuing 14-meter tsunami didn't just cut off all
electricity to the Fukushima Daiichi Nuclear Power
Station, setting the stage for a major nuclear accident.
The quake and tsunami-which reached over 20 meters in
height in certain areas of the country-also killed tens
of thousands of people, erased coastal towns, shut down
roads, and severed communications, paralyzing businesses
as well as the local and central governments. The
multifaceted, complex, cascading nature of the disaster
must be kept in mind in any assessment of the response
to it. In short: A lot was happening-all at once.

The nuclear accident was itself a compound disaster,
with meltdowns of reactor cores at Units 1, 2, and 3 and
problems with the cooling of spent fuel pools at Units 1
through 4 of the six-unit plant. A hydrogen explosion at
Unit 1 on the second day of the crisis exposed a spent-
fuel pool to the open air, released radioactive material
into the environment, and deteriorated the situation at
the plant, causing delays in cooling Unit 3. An ensuing
hydrogen explosion at Unit 3 then damaged seawater
injection lines and vent lines for Unit 2, producing
delays in cooling there. In other words, an accident at
one unit inevitably hampered responses to the situation
at another, leading to parallel chain reactions of
accidents and radiation releases.

As the crisis deepened, Prime Minister Naoto Kan
secretly instructed Shunsuke Kondo, chairman of the
Japan Atomic Energy Commission (AEC), to draw up a
worst-case scenario for the nuclear accident. This
contingency scenario was submitted to the prime minister
on March 25, 2011.1 It projected that the crisis could
deepen in the following manner:

    A hydrogen explosion occurs in the reactor vessel or
    containment vessel of Unit 1, releasing radioactive
    materials and damaging the containment vessel. Unit
    1 becomes impossible to fill with water.

    All on-site workers are forced to evacuate due to
    rising radiation levels.

    Units 2 and 3 become impossible to cool, even when
    filled with water. Water cannot be injected,
    moreover, into the spent fuel pool of Unit 4.

    Spent fuel becomes exposed in the pool at Unit 4,
    and the damaged fuel begins to melt. This melted
    fuel interacts with the concrete of the pool itself,
    producing a molten fuel-coolant interaction (MFCI)2
    and releasing radioactive materials.3

    The containment vessels of Units 2 and 3 are
    damaged, releasing radioactive materials.

    The fuel in the spent fuel pool at Units 1, 2, and 3
    are damaged and begin to melt, triggering MFCI and
    releasing radioactive materials.4

If the sixth stage of the scenario is reached, the
contingency document says, all residents living within
170 kilometers or more of the Fukushima plant might need
to be relocated, and relocation might need to be advised
for those living within 250 kilometers, since their
annual exposure to radiation would be much higher than
normal atmospheric levels. If such a worst-case scenario
becomes a reality, the document suggests, evacuation of
the 30 million residents in the Tokyo metropolitan area
could become necessary, depending upon wind direction.

In an attempt to gain an accurate picture of the causes
and background factors behind the crisis, the Rebuild
Japan Initiative Foundation5 established the Independent
Investigation Commission on the Fukushima Daiichi
Nuclear Accident in September 2011. The commission
consists of six respected experts from fields pertinent
to the investigation; it is chaired by Koichi Kitazawa,
former president of the Japan Science and Technology
Agency and a renowned scientist. Under the supervision
of the commission, a working group of about 30
professionals -- including researchers, lawyers,
journalists, and other specialists -- has interviewed
nearly 300 people involved in the Fukushima accident,
including then-Prime Minister Kan.

We, the authors, believe that a close examination of the
accident is not only essential for Japan's
reconstruction and energy policy -- including the country's
nuclear power component -- but also highly significant for
the international community. Risks associated with the
peaceful use of nuclear energy are certain to increase,
in light of the surge in nuclear plant construction
taking place in many emerging economies. It's clear from
our investigation of the Fukushima Daiichi accident
that, even in the technologically advanced country of
Japan, the government and the plant operator, Tokyo
Electric Power Company (Tepco), were astonishingly
unprepared, at almost all levels, for the complex
nuclear disaster that started with an earthquake and a
tsunami. And this grave oversight will affect the
Japanese people for decades. 

Lapses in preparedness

The Fukushima crisis revealed the dangers of building
multiple nuclear reactor units close to one another.
This proximity triggered the parallel, chain-reaction
accidents that led to hydrogen explosions blowing the
roofs off of reactor buildings and water draining from
open-air spent fuel pools -- a situation that was
potentially more dangerous than the loss of reactor
cooling itself. Because of the proximity of the
reactors, Masao Yoshida, the director of the Fukushima
Daiichi Nuclear Power Station at the time of the
accident, was put in the position of coping
simultaneously with core meltdowns at three reactors and
exposed fuel pools at three units.

The first 24 hours of the accident -- from the total loss
of power to the station on March 11, when standard
cooling stopped and damage to cores began, to the forced
injection of seawater the following day-were critical.
The most significant mistakes on that first day may have
been the misjudgment of the state of the isolation
condenser, and the 15-hour delay in venting Unit 1's
containment area to ease rising pressure.

At the outset of the accident, a Tepco worker misjudged
the backup cooling situation at Unit 1. He failed to
notice that the valve of the unit's isolation condenser,
or IC-a battery-powered emergency cooling system-was
either fully or partially closed after the plant lost
power. Steam usually spews out when the IC is activated;
because there was no sign of steam, the worker hastily
assumed that the IC system had lost its cooling water.
For fear of the mechanical damage that could occur if
the system were run without water, the worker removed
the IC from service for about three hours, starting at
around 6:30 p.m. on March 11.

The delays in venting reactor containments in the
immediate wake of the accident may have been the result
of assuming that battery-powered emergency cooling
systems were in operation.6 If this backup cooling
system were working, there would be less buildup of
pressure and hydrogen in reactor containments and less
need to vent them. Beyond this, most likely the Tepco
worker was distracted by a deteriorating situation at
Unit 2, as well. And even after top Tepco officials made
the decision to vent, there was a more than seven-hour
delay, the exact causes for which remain unclear.7
Whatever the reason for the delay, it resulted in the
creation of more hydrogen in the Unit 1 reactor vessel-
hydrogen that later was vented into the reactor
building, where it exploded, blowing the building's roof
off and exposing the reactor's spent fuel pool to the
environment.

Many human errors were made at Fukushima, a point
elaborated on in great detail in the interim report of
the Japanese government's Investigation Committee on the
Accident at the Fukushima Nuclear Power Stations, and
our investigative commission has incorporated some of
these findings in its report as well. But the role of
human error in the Fukushima nuclear accident was not
limited to the misjudgment of any one worker, like the
one who misjudged the backup cooling situation at Unit
1. The technical chief, the plant director, and the
nuclear energy section of Tepco's headquarters all
failed to ascertain the true operational situation of
the IC system at Unit 1.

In part, that failure may stem from Tepco's most recent
abnormal operating procedures, which were created in
1994 and do not address the possibility of a prolonged,
total loss of power at a nuclear plant. When on-site
workers referred to the severe accident manual, the
answers they were looking for simply were not there. And
those who misjudged the condition of the emergency
cooling system had never actually put the system into
service; they were thrown into the middle of a crisis
without the benefit of training or instructions.

Tepco bears the primary responsibility for the
incompetent handling of the aftermath of the disaster.
Behind the failure to prepare adequately for a major
accident are problems inherent in Tepco's management
structure and culture. For example, neither the chairman
nor the president-Tepco's top two managers-was at the
head office between Friday, March 11, and 10 a.m. on
Saturday, March 12, the most crucial period for dealing
with the accident. According to the explanation given by
Tepco, company Chairman Tsunehisa Katsumata was
traveling in China on a business trip, and company
President Masataka Shimizu was in Nara, a historical
town in the western part of Japan, sightseeing with his
wife, when the disaster happened. The closure of three
of the main Japanese transportation arteries-the Chuo
motorway, the Tomei motorway, and the Tokaido
Shinkansen, or bullet train-leading back to the Tokyo
area prevented Shimizu from returning by land, and a
tragicomic series of miscues related to air transport
kept him in western Japan until mid- morning on
Saturday.8 Tepco was consequently unable to make prompt
organizational decisions and wound up losing the
government's trust with regard to information sharing
and decision making.

But government regulators -- the Nuclear and Industrial
Safety Agency (NISA) and the Nuclear Safety Commission
(NSC) which oversees NISA's activities as the safety
authority -- share the blame for the poor response at
Fukushima. NSC did not include provisions for an
extended loss of power in its accident-management
policy. NSC regulatory guidelines for reviewing safety
designs of light water nuclear facilities specify that
the potential for an extended station blackout need not
be considered, as it is reasonable to expect that
transmission lines will be restored or emergency power
systems repaired quickly.

At Fukushima, however, transmission lines for external
power sources were not restored until March 17, and the
emergency power systems could not be quickly repaired.
The accident was the result of an extended loss of
electric power, so the regulatory guidelines- issued by
NSC and executed by NISA -- which stated that a station
blackout need not be considered played a large and
negative role in the events that transpired.

The Japanese government's unpreparedness also played a
role in exacerbating the Fukushima disaster. Perhaps the
most obvious indication of this systematic breakdown in
preparedness involves the nuclear emergency response
headquarters, or off-site center, for the Fukushima
plant. Such centers were established in the wake of a
1999 criticality accident at the Tokai nuclear fuel
conversion facility that exposed hundreds of workers,
responders, and residents to excess radiation levels;
the centers were intended to serve as frontline
headquarters for the coordination of responses to
nuclear accidents. In March 2011, however, the off-site
center for Fukushima, originally planned to be the base
to cope with nuclear disasters, was inoperative
throughout the crisis because of the destruction wreaked
by the earthquake and tsunami-roads were blocked and
electricity was out. Further, even without these
logistical problems, the center could not be used
because it was not fitted with such basic protections as
air-purifying filters.

Another preparedness breakdown involves SPEEDI, the
Japanese government's System for Prediction of
Environmental Emergency Dose Information. The system was
touted as able to provide forecasts for the diffusion of
radioactive materials during a nuclear event, but it
remained largely unused during the crisis because the
Nuclear Safety Commission and the Ministry of Education,
Culture, Sports, Science and Technology (MEXT) were
reluctant to release predictions claiming that the
simulated results were based on what several government
officials interviewed by our commission called
"unreliable emission source term." Despite widespread
environmental contamination by radioactive material
between March 11 and March 15-the time when the central
government made decisions about evacuating residents-
SPEEDI data were not officially provided to top leaders
in the Prime Minister's Office until March 23.
Evacuation orders were therefore issued without the
benefit of SPEEDI forecasts.

In hindsight, March 15 turned out to be a crucial
turning point; an early morning accident at Unit 2 led
to a dramatic rise in the diffusion of radioactive
materials from that site. This quashed any hope of
containing the radioactivity. SPEEDI was developed in
1984 for exactly this kind of situation; the system was
intended to help governments decide precisely when to
evacuate residents -- and from which specific areas. The
failure to use SPEEDI suggests that the heavy investment
in time and money to develop this system were for
naught. 

The trap of the absolute safety myth

Why were preparations for a nuclear accident so
inadequate? One factor was a twisted myth -- a belief in
the "absolute safety" of nuclear power. This myth has
been propagated by interest groups seeking to gain broad
acceptance for nuclear power: A public relations effort
on behalf of the absolute safety of nuclear power was
deemed necessary to overcome the strong anti-nuclear
sentiments connected to the atomic bombings of Hiroshima
and Nagasaki.

Since the 1970s, disaster risk has been deliberately
downplayed by what has been called Japan's nuclear mura
("village" or "community") -- that is, nuclear advocates in
industry, government, and academia, along with local
leaders hoping to have nuclear power plants built in
their municipalities. The mura has feared that if the
risks related to nuclear energy were publicly
acknowledged, citizens would demand that plants be shut
down until the risks were removed. Japan's nuclear
community has also feared that preparation for a nuclear
accident would in itself become a source of anxiety for
people living near the plants.

One example of the power of the safety myth involves
disaster drills. In 2010, the Niigata Prefecture, where
the 2007 Chuetsu offshore earthquake temporarily shut
down the Kashiwazaki-Kariwa Nuclear Power Plant, made
plans to conduct a joint earthquake and nuclear disaster
drill. But NISA advised that a nuclear accident drill
premised on an earthquake would cause "unnecessary
anxiety and misunderstanding" (Committee's interview
with Hiroyuki Fukano, NISA director, February 7, 2012)
among residents. The prefecture instead conducted a
joint drill premised on heavy snow.

The word used then to describe risks that would cause
unnecessary public anxiety and misunderstanding was
"unanticipated." Significantly, TEPCO has been using
this very word to describe the height of the March 11
tsunami that cut off primary and backup power to
Fukushima Daiichi.

But research on the Jogan tsunami of 869 AD has shown
that such heights should not be considered
"unanticipated" along the part of the Japanese coast
that includes the Fukushima nuclear complex (Minoura et
al., 2001). In fact, even Tepco's own nuclear energy
division understood that there was a risk of large
tsunamis at Fukushima (Sakai et al., 2006). However
these probabilities were ultimately dismissed through
the internal discussion of the division on the grounds
that they were "academic." Regulatory authorities, too,
had encouraged the company to incorporate new findings
regarding tsunami risks into its safety plans, but such
measures were not made mandatory.

So the March 11 tsunami was not unexpected. Yet Tepco
perpetuated the safety myth and did very little to back-
fit the existing nuclear systems to incorporate the
latest scientific findings and technological innovations
for improved safety. Making such changes, the nuclear
community felt, would be an admission that existing
safety precautions and regulations were insufficient and
that nuclear plants did not possess "absolute safety."
In this way, power companies found themselves caught in
their own trap. 

A problem of governance?

Japan's nuclear safety regulatory regime has been under
the dual jurisdiction of the Ministry of Economy, Trade,
and Industry (METI), which promotes nuclear energy use,9
and the Science and Technology Agency (now part of
MEXT). Supposedly, NISA enforces and NSC double-checks
the regulatory review-however, both agencies use the
same guidelines in their review. It should come as no
surprise that the problems with this clunky structure
have been criticized by the international community for
quite some time.

In June 2007, for example, the International Atomic
Energy Agency (IAEA) demanded clarification of NISA's
regulatory role and the role to be played by the NSC,
especially in the development of safety-assessment
guidelines (IAEA, 2007). In response, the NSC issued a
chairman's statement in 2008 dismissing the
recommendations and noting that Japan has been praised
highly for regulations that are, on the whole,
outstanding in the context of international standards
and that are functioning effectively to ensure nuclear
safety (Nuclear Safety Commission, 2008).

The NSC attitude typifies Japan's decades-long approach
to nuclear safety. Having great confidence in its
technical capabilities, the Japanese nuclear community
did not take the need for improvement of safety
regulations seriously before Fukushima; there was little
accountability, given the unclear jurisdictions,
complicated turf wars, and mountains of red tape that
connected and divided NISA, METI, NSC, AEC, MEXT, and
other entities with nuclear responsibilities. This is
not to mention the sweetheart relationships and
revolving door that connected the regulatory bodies and
electric companies, academics, and other stakeholders in
the nuclear community. The country's regulatory regime
and culture of safety assurance are out of sync with
global standards, evolving as they did in isolation and
within the complex vacuum of Japan's safety regulation
agencies.

As a regulatory agency, NISA lacked the philosophy,
capacity, and personnel to properly fulfill its role,
and it has consequently failed to train true safety
regulation professionals. Top NISA officials were unable
to answer the questions posed by members of the crisis
response team at the Prime Minister's Office and offered
no proposals to bring the accident under control.
Instead NISA simply conveyed to Tepco the government's
requests for updates on conditions at Fukushima Daiichi,
which was pointed out almost unanimously by the
politicians we interviewed.

The response to the Fukushima nuclear accident revealed
a crisis in the administration and enforcement of safety
regulations. To correct the problem, bureaucratic
sectionalism and duplicate safety regulations must be
eliminated, and the government needs to create a nuclear
regulatory authority that is not part of a ministry that
promotes nuclear energy use. Toward this end, the
government is considering the creation of a new nuclear
safety agency that would replace NISA and NSC and be
positioned as an external organ of the Environment
Ministry. Determining whether it can truly be
independent or better able to enforce safety regulations
efficiently and appropriately will require further
review.

Even if a new agency is created, a serious challenge
will remain: staffing the new entity with real experts.
The March 2011 crisis was a painful reminder that few
people are qualified and capable of grappling with an
actual nuclear disaster. Prime Minister Kan was so
frustrated with the ineptitude of top NISA officials
that he called in six outside experts to advise him on
technical matters in the wake of the Fukushima
accidents. Why were there no top officials at NISA with
professional knowledge? The answer to that question lies
primarily in Japan's bureaucratic and organizational
culture, under which NISA officials are regularly
reshuffled -- along with members of related agencies -- 
after serving in a position for only a few years.
Effective regulations will not be formulated and
enforced unless top officials in a regulatory agency are
experts in their respective fields and serve longer
terms. 

Taking responsibility: The public and private sector clash

Although the peaceful use of nuclear power is part of
the Japanese government's energy policy, nuclear power
generation is undertaken within the private sector. This
approach is not unique and is the model used in other
countries with nuclear power, including the United
States. But once Tepco's weaknesses in crisis
management, decision making, and governance were laid
bare, many wondered whether the company was really
capable of operating a nuclear power plant. Regardless
of the structure Japan establishes to conduct nuclear
power generation in the years ahead, there is a clear
need for the government to take responsibility for
nuclear power management and safety regulation. What
happened in the early days of the Fukushima catastrophe
illustrates that need.

When, on March 14, Tepco indicated that it might pull
all its workers from the Fukushima plant and leave the
failing facilities abandoned, Prime Minister Kan and
other top political officials stormed into Tepco's
headquarters in Tokyo and demanded that a joint response
headquarters be established. Clearly, the government
bears the ultimate responsibility for bringing a nuclear
accident under control.

Unfortunately, this wasn't the government for the job.
According to first-hand accounts by five top officials
in the Prime Minister's Office, the prime minister raced
into Tepco's headquarters at 5:35 a.m. on March 15 and
told more than 200 workers in its operation room that
abandoning the reactors and spent fuel pools would have
devastating effects over several months, creating 10 to
20 sources of radiation, each releasing two to three
times the contamination discharged at Chernobyl. It
didn't matter how much it cost to contain the disaster,
the prime minister said: Withdrawal was out of the
question when Japan's survival was at stake. Kan
mentioned that the United States or Russia would not
have any choice but to intervene in the Japanese
government's effort to control the nuclear disaster if
Tepco did nothing. He went on to say that Tepco was not
allowed to accept defeat and that the company bore the
ultimate responsibility. The workers, he said, should
put their lives on the line to salvage the situation.
Moreover, he concluded, if Tepco did withdraw, the
company would certainly be bankrupted by the accident.
When our commission asked Kan during an interview on
January 14, 2012, whether he really asked Tepco
employees to put their lives on the line, Kan didn't
directly answer the question, noting that there was no
law that could prevent Tepco from withdrawing from
Fukushima. But in his speech at Tepco on March 15, 2011,
he appealed to the workers' sense of duty, asking them
to remain on-site, protect the plant, and, thus, protect
Japan as a nation.

Even in a crisis, a Japanese leader cannot order
private-sector employees to die. Similarly, a senior
METI official responsible for nuclear energy told our
commission that the ministry has no authority to order
its officials to remain on-site if doing so would cost
them their lives. Because of these constraints, as a
final recourse, the government used members of the Self-
Defense Forces (SDF) -- who must obey orders -- to save
Fukushima. SDF personnel directed the efforts to inject
water into the reactors and fuel pools despite rising
radiation levels. They dutifully performed their
mission. 

Crisis management and leadership

In assessing Fukushima one year on, the deficiencies in
crisis management must be noted, as should the magnitude
of the limitations under which the prime minister and
other top leaders were operating. The key to effective
crisis management is the speed with which the
bureaucratic machinery can be shifted to operate in
emergency mode. In general, well-run bureaucracies place
the highest priority on compliance with the law,
fairness, efficiency, and bottom-up decision making. In
times of crisis, however, flexibility, improvisation,
clear identification of priorities, and top-down
decision making become more important.

Within the first days of the disaster, Fukushima Daiichi
Director Masao Yoshida ordered that seawater be injected
to cool Unit 1. But a hydrogen explosion, perhaps due to
a much-delayed venting of the containment vessel,
hampered the operation. Debris from the blast obstructed
access to water lines, so workers could not make the
necessary repairs, and some instruments and machines
were damaged at the site, further degrading the working
environment.

During a discussion of the seawater injections, Kan
asked about the possibility of re-criticality of the
damaged fuel in the Unit 1 reactor; Haruki Madarame,
chairman of the Nuclear Safety Commission, replied that
after a seawater injection, such a possibility "could
not be denied." Kan was not convinced by the argument,
and the discussion on seawater injection became tangled.
It took two more hours until they finally decided to
start the injections at Unit 1. This delay had an
enormous and unusual impact on Tepco.

The company's chief liaison with the government, Ichiro
Takekuro, notified the head office that further water
injections should be avoided until the government
decided on a course of action. Tepco President Shimizu
relayed this information to Fukushima Daiichi Director
Yoshida, who insisted on restarting injections as soon
as possible, leading to a heightening of tensions
between the head office and the on-site staff.

During a teleconference, Yoshida called the employee in
charge of the seawater injections to his side and
whispered in his ear -- so the microphone for the
teleconference with the head office would not pick up
his voice -- that though he would now order a halt to the
seawater injections, the employee should disregard the
order and continue. Thereupon, Yoshida loudly declared
to all teleconference participants that water injections
would be interrupted.

Yoshida's kabuki play successfully helped Tepco avoid
further confrontations with the government, while
ensuring that the cooling of the reactors would
continue; at this point, the company's Fukushima Daiichi
plant team was working independently of their
headquarters. That the on-site director in Fukushima
needed to go to such lengths to avoid a further
deterioration of the nuclear crisis shows the extent to
which relations between the Prime Minister's Office and
Tepco and communication between Tepco's headquarters and
the company's on-site managers had broken down.

Because all the ordinary means of filling the pools had
been disabled by the earthquake and tsunami, the only
option was to mobilize the police, the SDF, and the fire
department-agencies that are usually first on the scene
during emergencies. None of these groups, however, had
ever been called upon to spray water into fuel pools,
and they had never received training for such a
dangerous and difficult task. Unsurprisingly,
information sharing did not go smoothly: SDF did not
have a site map of the nuclear plant because Tepco
employees feared this would violate security
regulations.

But the biggest problem with the government's crisis
management was probably the amateurish level of its
crisis communications. To be sure, information was, for
the most part, insufficient, and there was little time
to assess its reliability before dissemination. Still,
the government's crisis communication efforts often were
abysmal.

When, at a press conference held on the second day of
the crisis, NISA Deputy Director Koichiro Nakamura
acknowledged the possibility of a core meltdown, Chief
Cabinet Secretary Yukio Edano demanded that reactor
updates only be communicated with approval from the
Prime Minister's Office. Nakamura was dismissed from his
post later that evening, and his assessment of a
potential meltdown was rejected. The Prime Minister's
Office then functioned as a micromanager, only further
complicating the process. Kan personally visited the
plant, circumventing the NISA director and directly
contacting lower-ranking NISA managers with questions
about minor technical details.

Moreover, Kan's often-abrasive comments and questions
could seem like cross-examinations; they made many
officials and advisers shrink under his direction. In a
December 17, 2011, interview with our commission, NSC
Chairman Madarame said the prime minister became overly
excited after a March 14 hydrogen explosion at Unit 3
that led to the injury of some SDF soldiers on-site. For
a couple of days, Kan and other officials were driven by
a fear that public disclosures of radiation levels would
cause widespread panic. This gave the impression that
the political leadership had fallen into a sort of
"elite panic."10

Despite the government's efforts to downplay the
seriousness of the situation, this hydrogen explosion
made the severity of the crisis clear, and public
confidence in the government rapidly declined. The
majority of the general population had no idea of the
meaning behind the reported radiation levels. There was
no yardstick against which to judge whether or not the
levels were dangerous. The government made no effective
effort to educate or soothe the public in this regard.
For example, in many evacuation zones, men wearing white
protective uniforms would arrive at a house and order
the residents to evacuate; they often did this without
explaining the reasons for the evacuation. 

Resilience

Though much of the response to Fukushima was an utter
failure, the reality is that it actually could have been
worse had lessons not been learned from previous crises.
Tepco had certainly failed to put in place adequate
tsunami countermeasures at Fukushima Daiichi, such as
reinforcing the embankment and protective system for
cooling system water pumps -- but some measures taken after
the earthquakes at other nuclear plants such as Onagawa,
owned by Tohoku Electric Power Company, and Tokai, owned
by Japan Atomic Power Company, paid off, and these
facilities were able to escape the total loss of power.
After the 2007 earthquake in Chuetsu, a seismically
strengthened building was built at Fukushima Daiichi;
this building, though it did receive some radioactive
contamination in 2011, was unharmed by the earthquake
and tsunami. Had it not been available for use as an
emergency headquarters, the accident could not have been
brought under control.

Quality crisis management includes the drawing of
lessons from disaster. This process involves studies
into the causes of accidents and responses to those
causes, the charting of new goals for minimizing the
risk of disaster, and the building of a national
consensus around realizing those goals. Ultimately, the
final outcome of studies of Fukushima Daiichi should be
an intense effort to build up the resilience of the
country, its organizations, and its people, so future
disaster can be averted or responded to effectively.

When it comes to nuclear disasters, no two are exactly
the same. So legislation and manuals do little to add
clarity or direction to the situation. At Fukushima
Daiichi, the problems were not with the law or the
manual, but with the humans who formulated the
"anticipated" risks that fell in line with corporate and
political will -- but did not represent the actual risks
the nuclear plant faced and posed.

A personal aide to Prime Minister Kan confided to the
independent investigation that he felt the Japanese have
all the luck, or must have been blessed to be able to
live through this ordeal, given its enormity and the
truly existential threat it posed. In light of the
worst-case scenario submitted to Kan, the remark is
especially poignant. After all, just as no two disasters
are identical, no two measures of luck will ever be
exactly the same.

Funding

This research received no specific grant from any
funding agency in the public, commercial, or not-for-
profit sectors. 

Author biographies

Yoichi Funabashi is chairman of the Rebuild Japan
Initiative Foundation and a distinguished guest
professor at Keio University. Funabashi is a former
editor-in-chief of the Asahi Shimbun. His books in
English include The Peninsula Question: A Chronicle of
the Second Korean Nuclear Crisis (Brookings Institute,
2007); Reconciliation in the Asia-Pacific, ed. (USIP,
2003,); Alliance Tomorrow, ed. (Tokyo Foundation, 2001);
Alliance Adrift (Council on Foreign Relations Press,
1998, winner of the Shincho Arts and Sciences Award);
Asia-Pacific Fusion: Japan's Role in APEC (Institute for
International Economics, 1995, winner of the Mainichi
Shimbun Asia Pacific Grand Prix); and Managing the
Dollar: From the Plaza to the Louvre (Institute for
International Economics, 1988, winner of the Yoshino
Sakuzo Prize).

Kay Kitazawa is staff director of the Rebuild Japan
Initiative Foundation's Independent Investigation
Commission on the Fukushima Daiichi Nuclear Accident.
Kitazawa is a specialist in city planning and
management, advising prefectural governors and mayors in
Japan. Before joining the foundation she worked at the
London School of Economics and Political Science,
developing urban policies for the world's growing
metropolises. 

Article Notes

*1 The Independent Investigation Commission on the
Fukushima Daiichi Nuclear Accident was able to obtain a
copy of this document.

*2 An MFCI takes place when nuclear reactor fuel rods
interact with water after a core meltdown, causing an
explosion.

*3 It is unlikely that the pool would have melted even
if left uncooled. It is likely, however, that it would
have become hot enough to release its contained
cesium-137.

*4 To get to this point, a steam zirconium reaction
would have generated hydrogen and oxydized the cladding,
followed by a zirconium fire and a release of
cesium-137.

*5 The Rebuild Japan Initiative Foundation is a newly
established private think tank; its sponsors do not
include people or businesses directly connected to the
Fukushima Daiichi accident. The foundation's independent
investigation is separate from official inquiries by the
Japanese government and the National Diet. Publication
of the foundation's Japanese-language report is slated
for the end of February 2012, with release of the
English version planned for next summer.

*6 At Fukushima Daiichi, Unit 1 is equipped with an IC
emergency cooling system. The newer Unit 2 and Unit 3
have more sophisticated reactor core isolation cooling
(RCIC) systems.

*7 Haruki Madarame, chairman of the Nuclear Safety
Commission, and Ichiro Takekuro, Tepco's chief liaison
with the government, started sharing their awareness of
the need to vent containments with top policy makers at
about midnight on March 11. At Tepco headquarters, the
company's president, Masataka Shimizu, approved the
venting of Units 1 and 2 around 1:30 a.m. on March 12
and then notified the Prime Minister's Office, the
Ministry of Economy, Trade, and Industry, and the
Nuclear Safety Commission. But the venting did not occur
for hours. Tepco argued that technical difficulties
prevented a swift venting. Lack of information on the
progress of venting irritated top policy makers,
creating mistrust in Tepco's ability to handle the
situation. The prime minister issued an evacuation order
for residents within 10 kilometers of Fukushima Daiichi
at 5:44 a.m. on March 12. Economy, Trade, and Industry
Minister Banri Kaieda, who holds jurisdiction over
nuclear policy, issued an official order of venting to
Tepco at 6:50 a.m. Tepco did not carry out the venting
until 9:04 a.m.

*8 Shimizu tried to hire a private helicopter from
Nagoya Airport on the evening of March 11, only to find
that Japanese aviation law prohibits private helicopters
from taking off after 7 p.m. He then turned to the
Ministry of Economy, Trade, and Industry and to the
Ministry of Defense, via the unofficial channel of the
Office of the Prime Minister, for the use of a
helicopter from the Japan Air Self-Defense Force. A
C-130 transport aircraft, with Shimizu onboard, finally
took off from Nagoya Komaki Air Force Base around 11:30
p.m., but the airplane received an order from the
Ministry of Defense to turn around 10 minutes after
takeoff; Defense Minister Toshimi Kitazawa wanted the
Self- Defense Force to prioritize the transfer of
earthquake and tsunami victims. Shimizu at last arrived
in Tokyo by private helicopter at 10 a.m. on March 12.

*9 This ministry was formerly known as the Ministry of
International Trade and Industry.

*10 The term was coined by Lee Clarke and Caron Chess
(Clarke and Chess, 2008).

References

Clarke L, Chess C (2008) Elites and panic. Social Forces
87(2): 993-1014. Abstract/FREE Full Text

International Atomic Energy Agency [IAEA] (2007)
Integrated Regulatory Review Service Report. December.
Available at:
http://www.meti.go.jp/press/20080314007/report.pdf.

Minoura K, Imamura F, Sugawara D, Kono Y, and Iwashita T
(2001) The 869 Jogan tsunami deposit and recurrence
interval of large-scale tsunami on the Pacific coast of
northeast Japan. Journal of Natural Disaster Science 23:
83-88. Available at:
http://jsnds.org/contents/jnds/list.html.

Nuclear Safety Commission (2008) NSC Chair's views upon
receipt of the IAEA IRRS Report. March 17. Available at:
http://www.nsc.go.jp/NSCenglish/documents/statement/2008/20080317.pdf .

Sakai T, Takeda T, Soraoka H, Yanagisawa K, Annaka T
(2006) Development of a probabilistic tsunami hazard
analysis in Japan. Presentation delivered at the
International Conference on Nuclear Engineering. Miami,
FA, July 17-20. Available at:
http://jsmillerdesign.com/FukushimaPapers/Development%20of%20a%20Probalistic%20Tsunami%20Hazard%20Analysis%20in%20Japan.pdf.

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