The response of central and local government agencies to the Fukushima nuclear power plant accident
S. Abe Kansai University, Osaka, Japan
Abstract
This chapter reviews how central and local governments responded to the emergency situations. Necessary actions were spelled out in the Nuclear Emergency Preparedness Act; however, the magnitude of the disaster made effective action difficult, and both central and local governments had to take actions without sufficient information. The primary regulatory bodies, the Nuclear Safety Commission and Nuclear and Industrial Safety Agency, struggled to perform their emergency response tasks.
3.1 Introduction
The Fukushima-1 Nuclear Power Plant (NPP) accident was triggered by the combined natural disasters of earthquake and tsunami; however, the Tokyo Electric Power Company’s (TEPCO) insufficient preparation against accidents and disasters, its weakness in managing the accident, and deficiencies in government nuclear disaster preparedness turned the accident into a serious nuclear disaster of International Nuclear Events Scale (INES) Level 7 (see comments on TEPCO’s performance in Refs. [10–12] as well as comments on the government’s response in Refs. [13–16]; see also Refs. [17,18]).
In terms of measures for accident and disaster prevention, the Nuclear and Industrial Safety Agency (NISA) and TEPCO’s preparations against tsunami and severe accidents were insufficient, lacked precautions against large-scale complex disasters, and did not have disaster prevention or evacuation plans in case of Containment Vessel (CV) damage and a large radiation release from the plant.
TEPCO, after the accident, made a number of serious errors in the field. Both the central and the local government are also responsible for a share of blame due to the lack of plans for preventing magnification of damage, monitoring, making use of the System for Prediction of Environmental Emergency Dose Information (SPEEDI), giving effective evacuation directions to the residents, taking measures against exposure to radiation, and making public announcements to the people of Japan and overseas (see Refs. [19–21] for comments on government response and also see Refs. [17,18]).
This chapter discusses the problems of the central and local government agencies. The appendix at the end of this chapter lists all the organizations and people that are mentioned in this book. The indentation indicates the organizational hierarchy and the person’s affiliation.
3.2 Central government: key responsibilities and preparatory measures
3.2.1 The “defense in depth” strategy
The International Atomic Energy Agency (IAEA) was created in 1957 to promote the use of nuclear energy for peaceful purposes and to prevent its misuse for weapons. IAEA has been promoting the concept of “defense in depth” to ensure safety within nuclear power facilities.
In 2006, IAEA, joined with eight other international organizations, including the European Atomic Energy Community (EURATOM), the OECD Nuclear Energy Agency (OECD/NEA), and the World Health Organization (WHO), to consolidate three documents about safety principles, “The Safety of Nuclear Installations,” “The Principles of Radioactive Waste Management,” and “Radiation Protection and the Safety of Radiation Sources,” and establish “Fundamental Safety Principles” into a coherent and consistent set of ten new principles [1]. Principle 8 of this set of ten new principles states the primary means of preventing and mitigating the consequences of accidents is “defense in depth.”
IAEA states, “The primary means of preventing accidents in a NPP and mitigating the consequences of accidents if they do occur is the application of the concept of defense in depth. This concept is applied to all safety-related activities, whether organizational, behavioral or design related, and whether in full power, low power or various shutdown states” [1]. This “defense in depth” has the following five levels.
Defense Level 1 Defense at this level aims at preventing deviation from normal operation and also preventing safety-related malfunctions and failures. For this purpose, commissioning, design, construction, maintenance, and operation have to proceed in a sound and conservative manner.
Defense Level 2 The purpose of defense at this level is to detect anticipated operational occurrences deviating from normal operation and to prevent a situation from developing into an accident. For this purpose, the design has to prepare special systems and mechanisms, and their effects have to be verified with safety analyses to prevent such occurrences or minimize their effects, and furthermore, operational procedures have to be in place to return the plant to a safe state.
Defense Level 3 A postulated initiating event during operation may develop into a situation uncontrollable with Defense Level 2 and into an accident. The plant design shall take such accidents into account and equip the plant with safety mechanisms, safety systems, and procedures to return the plant to a safe state and prevent core damage and radioactivity release to the surrounding area outside the plant.
Defense Level 4 Defense at this level ensures the confinement function by reliably keeping the radiation release to the lowest possible level to mitigate various accident effects from failure in Defense Level 3.
Defense Level 5 Defense at this level targets mitigating the radiation effects from radioactivity release caused by an accident state. Defense calls for preparing a well-equipped emergency control center, as well as emergency plans and emergency procedures within the area and also in surrounding regions to counter emergency situations.
Table 3.1 summarizes these five levels of defense. In Japan, such defense in depth is also called multilayered protection; however, in Japan the fourth and fifth levels had never gone through serious evaluation. Both the regulators and the industry only took measures up to Defense Level 3 for their defense in depth.
Table 3.1
Summary of defense in depth
| Defense level | Target/purpose of defense |
| 1 | Prevent deviation from normal operation |
| 2 | Detect anticipated operational occurrences and prevent their development into accidents |
| 3 | Moderate effects of accidents from postulated initiating events |
| 4 | Action against severe accidents |
| 5 | Countermeasures against radiation release caused by accidents |
In other words, guidelines for safety design reviews and technical standards have addressed, to some extent, nuclear plant defense up to Level 3; however, as we will later describe, the higher Levels of 4 and 5 have only been partially planned: Defense Level 4 through evaluation and application of accident management as instructed by regulation, Defense Level 5 within the framework of “Act on Special Measures concerning Nuclear Emergency Preparedness” [2]. The preparations in place were not at the level IAEA required.
Fukushima-1 had some preparations in place for Levels 1 through 3. For example, by 1999, the plant had added diesel generators and evaluated installing air-cooled generators. The plant made these improvements as part of accident management in response to Level 3 as we will discuss later. These steps, however, were not a plant design of measures against situations where uncontrollable initial events could turn into accidents; thus, the modifications cannot claim to be defense in depth preparations to Level 3.
3.2.2 Assessing the performance of the main government departments in safety regulation and disaster management
This section reviews the problems with the Japanese regulatory bodies in terms of Defense Level 4.
Nuclear reactor facilities by design have multiple levels of countermeasures against unexpected incidents and accidents. The 1979 Three Mile Island (TMI) and 1986 Chernobyl accidents, however, have shown us that severe accidents that damage the reactor core beyond the design standards can happen.
Thus, in the 1980s and 1990s, international discussions began about how to counter such severe accidents. The discussions led to international acceptance of the basics of ensuring NPP safety so that licensing is granted to safety assurance to within the framework of design standards of nuclear reactor facilities, and serious accidents that exceed the design standards and damage the core or nuclear fuel are handled through measures against severe accidents. Each country then established its own severe accident measures.
At this time, Japan started discussions about severe accident measures as well; the Nuclear Safety Commission, which had been analyzing the TMI and Chernobyl accidents, set in 1987 a Common Problem Round-Table Group within the Special Committee on Nuclear Reactor Safety Standards to evaluate measures against severe accidents. The group issued a report in March 1992. Based on this report, NSC announced, two months later, its decision “Accident Management: Measures against Severe Accidents at Light Water Nuclear Reactor Facilities for Power Generation” [3].
The decision stated “Events that exceed the design standards may rarely cause large damage to the core, and Accident Management are measures that prevent the development of such events into severe accidents or even if they have developed into severe accidents, moderate their effects with safety margins within the current design, with accountable functions that are beyond their original functions, or with effective use of newly installed equipment in preparation to such situations” [3].
The preceding definition in Japanese did not contain the Japanese word for “severe accident” and instead used the phonetic sound of the English phrase “severe accident” in the Japanese alphabet. Calling this definition “Accident Management” suggested an assumption that severe accidents were unlikely.
This decision by the Nuclear Safety Commission set the later fundamental direction in Japan in terms of severe accident measures and accident management. These are summarized as follows:
(1) Safety of Japanese nuclear reactor facilities has complete assurance based on the concept of multilayered protection and strict safety assurance measures. The possibility of severe accidents is negligibly small from an engineering standpoint, and risks with nuclear reactor facilities are sufficiently small.
(2) Preparing accident management measures further lowers this already low risk; thus, each nuclear reactor owner is encouraged to make voluntary efforts to prepare them.
In other words, the decision implied that the possibility of severe accidents in Japan is very small, and voluntary efforts by the utility companies would suffice in dealing with them. Chapter 4 will discuss problems with TEPCO’s accident management.
This decision was questioned after the Fukushima NPP accident, and the Nuclear Safety Commission, on October 20, 2011, abandoned it. In the statement then issued, the Commission Chair stated as follows:
The occurrence of this accident revealed that we had serious problems with our idea that “risk is sufficiently low” and with the effectiveness of voluntary efforts by the utility companies in further lowering the risk. The definite problem lied in the fact that despite the large risks of external events had been pointed out, especially with earthquakes and tsunami, actual measures failed to fully account for such risks. Preparing accident management for all nuclear reactor facilities took a total of 10 years, and they had their bases in countermeasures against occurrences identified by probabilistic risk analysis of internal events made in 1994 and the bases had never been reevaluated. Furthermore, no one recognized the possible failure of equipment or procedures for accident management.
3.2.3 Assessing the use of severe accident measures
When the Nuclear Safety Commission was discussing severe accident measures, the Ministry of International Trade and Industry (MITI, now merged into METI) regulated the safety of nuclear reactors for power generation. After the decision by the Nuclear Safety Commission, the ministry composed “Future Processes of Accident Management” [4]. At the same time, it announced a notice to business directors of public utilities titled “Preparing Accident Management in Nuclear Power Plants” [5]. This notice acknowledged the need for severe accident measures; however, it was in line with the commission’s understanding that accident management as a measure against severe accidents was up to voluntary actions by each utility company.
The following circumstances had MITI take the stance that the utility companies were to carry out independent actions for accident management.
Fundamentally, those involved had the mind-set that regulations at the time did in fact provide sufficient safety for Japanese nuclear reactors. This appeared to be supported by probabilistic safety assessment (PSA). PSA is a method for overall quantitative evaluation of safety of nuclear reactor facilities by quantitatively analyzing frequencies of events that lead to abnormality or accidents within nuclear reactor facilities, probability of loss of safety functions for mitigating the effects of such events, and the processes and effects of these events. The method concluded that the probability of severe accidents occurring in Japan were 10-6/reactor-years, a probability less than the IAEA target at the time of 10-4/reactor-years for old reactors and 10-5/reactor-years for new ones. The administration thus believed that the regulation at the time was sufficient to ensure safety.
Another potential consideration was to avoid the risk of complicated lawsuits. Ever since NPP construction became more frequent in a number of regions in Japan, a number of lawsuits had been filed against the government seeking cancellation of the licensing of the nuclear reactors. The government claimed the regulation back then was sufficient for safety assurance of nuclear reactors. The administration judged that if they required new laws and regulations to take actions for severe accident management, it might be seen to admit flaws in regulations at the time, and facilities that had been built previously would face difficulties with ongoing litigation.
There are, however, two types of factors that can lead to severe accidents that exceeded existing design standards: internal factors and external factors. Internal factors are troubles within the NPP (e.g., failure of equipment or human error by the operator), and external factors include possible natural phenomena like earthquakes, flooding, tsunami, wind, freezing weather, snow, and landslides, in addition to external human-caused factors like airplane strikes, destruction of dams, or explosion [17,18,22].
Severe accident measures counter these events that exceed the design standards, and thus, the internal and external factors should have been evaluated separately.
When MITI started evaluation of accident management, it had the intention to first start with internal factors of machine failures and human error and then to continue with external factors like earthquakes. As MITI discussed the evaluation with utility companies, external factors were pushed back for later review. Accident management by utility companies, thus, only addressed internal failures and human errors in the area of severe accident measures (Figure 3.1).
This is how the regulatory organizations and utility companies developed the belief that NPPs have sufficient safety measures and did not pursue the severe accident measures of accident management on external factors. As a result, Fukushima-1 lacked proper preparation against a tsunami-induced complete loss of electrical power and failed to cool its nuclear reactors.
The accident has shown us that severe accident measures should not have been left to voluntary actions by utility companies but instead, should have been managed with appropriate laws and regulations.
3.2.4 Assessing the response to extended station blackout (SBO)
Countermeasures against SBO are among the most important of severe accident measures. Fukushima-1 lost all its external power supplies and most of the internal power supplies, lost the core cooling functions, and headed into a severe accident.
SBO is a state in which all external electrical power supplies and on-site electricity supplies from all emergency sources are lost. It is an extremely serious threat to maintaining the safety of NPPs. Thus, in Japan, the Review Guide for Safety Design by the Nuclear Safety Commission (formerly the Atomic Energy Commission up to 1978) had listed securing electrical power sources as a requirement in the Guidelines. The Atomic Energy Commission document, “Review Guide for Safety Design of Light Water Nuclear Power Reactor Facilities” [25], made public in June 1977, stated Guideline 9 as follows:
Guideline 9: design checkpoint against power outage
A NPP design shall, upon a short SBO, safely stop the nuclear reactor and then assure cooling after the stop.
There is, however, no need to plan against a simultaneous functional loss of electric power facilities with their high level of reliability [25].
These guidelines are supported with comments to clarify meanings and interpretation. The comment for Guideline 9 stated as follows:
Evaluation of extended SBO is not required because quick recovery of the power line or diesel generators is expected.
“High level of reliability” means keeping the emergency power supply system up at all times to avoid startup failure of specific equipment or having multiple units with high reliability available on-site, each with an independent power supply [25].
The Nuclear Safety Commission, in August of 1990, revised the “Review Guide for Safety Design of Light Water Nuclear Power Reactor Facilities,” and the guideline for cases of power outage was moved to Guideline 27, which stated as follows:
Guideline 27: design checkpoint against power outage
Nuclear reactor facilities shall be designed against a short SBO to stop the nuclear reactor safely and ensure cooling after such stopping [23].
The comments explained Guideline 27 as follows:
Evaluation of an extended SBO is not required because quick recovery of the power line or diesel generators is expected.
When the emergency AC power supply facility has high reliability with its system structure or operation (e.g., by keeping it up and running at all time), SBO does not need to be evaluated in design [23].
The safety design review guideline by the Nuclear Safety Commission is used for double-checking, and its articles, strictly speaking, are not laws or regulatory requirements for utility companies. If a company, however, is not following them, it will have a hard time passing the review by this regulatory organization. For utility companies, in reality, these articles were equivalent to laws or regulatory requirements. This specific Guideline 27, however, had the following problem.
The Atomic Energy Commission and the Nuclear Safety Commission interpreted “short” in Guideline 27 to mean 30 min or less since 1977. This understanding caused utility companies to interpret the capacity requirement on chargeable batteries to last at least 30 min in case of SBO.
The guideline was written under the assumption that failure of off-site power sources and on-site supplies were independent, and simultaneous failure of both supplies and damage on the switchboard had never even been evaluated. Such assumptions were clearly an oversight on the part of those involved with editing this safety design review guideline.
In the earlier safety reviews, some technical experts had repeatedly asked about the reason for the setting of “short time” to 30 min and why there was no evaluation of extended SBO during nuclear safety committees; however, the discussions never led to doubts about the reviews themselves or adequacy of the guidelines. The guideline saying that “an extended SBO does not require evaluation” remained for years.
3.2.5 Assessing the countermeasures in the event of a tsunami
Fukushima-1 NPP was, at first, licensed with a design wave height of 3.1 m. Emergency seawater pump facilities for Units 1 through 4 were built on a 4-m bedrock and the reactor and turbine buildings on 10 m. The wave height of 3.1 m was based on the tsunami from the 1960 Chile earthquake. The construction was doomed to lose seawater cooling with a tsunami runup height of 4 m and DC power and emergency diesel generators with a runup height of 10 m.
TEPCO later reviewed the expected tsunami height and revised the highest wave attack to Fukushima-1 at 5.7 m and later at 6.1 m. In 2002, the emergency seawater pumps were lifted as we later describe in Chapter 4. This later work ensured that the emergency seawater pumps would maintain their cooling function to prevent core damage even with the loss of other facilities on the 4 m bedrock. In reality, however, the tsunami from the Tohoku Area Pacific Offshore Earthquake reached a height above 10 m, and the reactor cooling function was lost.
In July 1993, the Southwest Hokkaido offshore earthquake occurred, and a number of tsunami waves affected Okushiri Island and other areas. The severe damage from this tsunami led MITI to order reevaluation of safety against tsunami to existing nuclear power facilities. TEPCO replied by submitting “Fukushima 1 and 2 Tsunami Safety Evaluation Report” to MITI. This indicates that regulatory bodies had recognized the risk of tsunami to some extent since the 1990s.
The Nuclear Safety Commission, with responsibility for setting the guidelines for the safety design review of NPPs, had plans to include articles about countermeasures against tsunami as phenomena that accompany earthquakes in their guidelines. The commission’s committee administration office, also had recognized the need to discuss tsunami in the guidelines.
Before taking on the revision work, thorough discussions about earthquake preparation took place in the Nuclear Power Engineering Corporation (NUPEC, closed in March of 2008 with its work transferred to JNES and The Institute of Applied Energy); however, no independent discussions on earthquakes were held, and no tsunami specialist was in the antiseismic work group. A tsunami wave was understood as a phenomenon that may follow an earthquake, and once its origin is set, a computer simulation can calculate the wave height; thus, they saw no need for a tsunami expert.
The history of tsunami, however, with information on damage caused, countermeasures taken, and their characteristics, are hard topics for seismic specialists. The lack of a tsunami expert in the work group clearly reveals the limited understanding of the Nuclear Safety Commission members at the time about the significance of possible problems with a tsunami.
The revision of the Guidelines for Anti-Seismic Design Review by the Nuclear Safety Commission took five long years to complete in September of 2006 [6]. The last chapter of the final version was “8. Discussions on Phenomena that Accompany Earthquakes,” including landslides at slopes surrounding facilities and tsunami. The requirement for tsunami preparation stated, “Although extremely rare, a tsunami is possible while the facilities are in service, and thus assuming its occurrence is adequate. Facilities shall be designed so their safety functions are not severely affected even upon a tsunami attack.” It was a step forward that the guidelines mentioned countermeasures against tsunami; however, the sentence did not trigger any new tsunami preparation, and TEPCO and other utility companies did not make any major changes to their tsunami preparations.
3.3 The response and preparedness of the central government
3.3.1 Assessment of emergency measures from the Nuclear Emergency Preparedness Act guidelines
Lessons from the 1999 JCO criticality accident in Tokai, Ibaragi prefecture, led to the issuance of the “Act on Special Measures concerning Nuclear Emergency Preparedness (Nuclear Emergency Preparedness Act)” in the same year to enhance the response to nuclear power accidents. The law called for a local emergency response headquarters with a commander armed with authority delegated by the prime minister. The “Nuclear Disaster Countermeasures Manual (Nuclear Emergency Preparedness Act Manual)” was also made available. The manual was based on this law and was constructed under the condition that the local headquarters would play a central role.
We next review whether these systems for countering nuclear disasters functioned as designed during the Fukushima-1 NPP accident.
At 19:03 on March 11, 2011, the government declared a Nuclear Emergency Situation and set up the Nuclear Emergency Response Headquarters (NERHQ) headed by the Prime Minister Kan in his office, and the local emergency response headquarters in the off-site center in the town of Ohkuma in Fukushima prefecture. The administration office for NERHQ was set in the METI emergency response center. Following the Nuclear Emergency Preparedness Act Manual, METI Vice-Minister Ikeda, TEPCO Vice-President Mutoh, and other primary members gathered at the off-site center to start the local response headquarters.
The off-site center, however, had suffered damage from the earthquake, most of its communication equipment was unusable, and the building had no protection against radioactivity. Because of the difficulty in using the center, the local response headquarters were transferred to the prefectural government office on March 15th. The local response headquarters, thus, failed to function in the initial stage as the emergency command center.
The headquarters in Tokyo had to cover responsibilities originally intended for the local headquarters and be at the very front of the disaster response. Top officials of the ministries and agencies gathered at the crisis management center in the basement of the Prime Minister’s office, which had already been set up after the Tohoku Area Pacific Offshore Earthquake. This center in the basement, however, proved inadequate and instead, Prime Minister Kan and the people around him in the fifth floor of the Prime Minister’s Office Building (and partially in the concourse level between the first floor and basement) made the critical decisions. Prime Minister Kan himself was at the very front of the response by actively gathering information himself and even flying to the accident site to observe the situation.
The main reason why the Tokyo response headquarters was not used reflected weaknesses in NISA, including receiving proper information from local offices and TEPCO as well as a broader lack of readiness for a disaster on this scale.
To resolve this situation, the Fukushima NPP Accident Response General Headquarters (General Headquarters) was set up inside TEPCO’s headquarters main office in Tokyo. Prime Minister Kan was in charge of the headquarters with Minister Kaieda of METI and President Shimizu of TEPCO serving as Assistant Chiefs.
This General Headquarters contributed hugely to the accident response with its teleconferencing system by establishing real-time communication with the Fukushima-1 Plant Response Office to share status and work progress information among the government, TEPCO, and NISA. This General Headquarters in practice served as the emergency response center in place of the government NERHQ.
As explained earlier, the fifth floor of the Prime Minister’s Office Building, not specified in the Nuclear Emergency Preparedness Act or Nuclear Emergency Preparedness Act Manual, took the role of the command center and then from March 15th onwards, the role was passed to the General Headquarters with Prime Minister Kan at the forefront (Figure 3.2). The lack of preparation of local response headquarters and NERHQ administration, an insufficient system for collecting information, and poor support from the Nuclear Safety Commission led to such an unplanned situation.
The Nuclear Emergency Preparedness Act, at a glance, seems to be a well-prepared law; however, it was written for a locally containable accident like the JCO criticality accident and was not intended for a complex, large-scale, widely spread disaster as developed this time. Therefore, it was only natural that Nuclear Emergency Preparedness Act and its Manual failed to work.
3.3.2 Response of the regulatory organizations to system failures at the Fukushima NPP
NISA was an organization in charge of safety regulation of power-generating nuclear power facilities and, at the same time, was responsible for taking the central role in disaster response in case of nuclear power accidents with commercial reactors by administering NERHQ.
NISA, however, at time of the Fukushima-1 NPP accident, displayed weakness in a number of aspects:
(i) It failed to effectively collect information to transfer to the Prime Minister’s Office and related ministers and agencies.
(ii) It did not explain sufficiently the status, progress, necessary measures, and articles of Nuclear Emergency Preparedness Act to the Prime Minister’s Office in case of nuclear power disasters.
(iii) Although having radiation spread information from SPEEDI available, it interpreted it as inapplicable without the radiation source information and did not make use of it.
(iv) It failed to perform its duties as the administration office, such as delegating authority to the local response headquarters.
NISA also did not have input in working out mid- to long-term projects for preventing nuclear disasters by safety regulations for severe accident responses. The result was that it failed to order the utility companies to take adequate severe accident measures.
Knowledge and problems relating to nuclear safety are closely related to the field; thus, keeping up with the skills for safety assurance may be difficult for the regulating body. Practical and specialist knowledge about safety and technology at the level of a utility company and ability in making difficult decisions and performing tasks are required. Such qualifications should be posed not only on individuals in the workforce; organizational and systematic functions for safety assurance are also needed. NISA, in addition to the aforementioned shortcomings, lacked sufficient resources in this respect.
The lack of protection against radiation at the off-site center clearly shows NISA’s lack of preparation. An off-site center is where the local response headquarters will be set to take the central role in emergency situations in case of nuclear disasters. The off-site center for Fukushima-1 was located in the town of Ohkuma about 5 km from the accident site.
The center, located so close to the NPP, did not have an air-cleaning filter to block radioactive material in the air. On March 14th, after the reactor building of Unit 3 blew up lifting the level of radiation, staff had to abandon the off-site center. In other words, this was a facility prepared in case of a nuclear disaster; however, its structure lacked any preparation against a rise in radiation.
The Ministry of Internal Affairs and Communications (MIC) took about 1 year from January 2008 to carry out an administrative evaluation and monitoring of overall administration of nuclear disaster prevention aimed at improving related ministries and agents. Of the 22 off-site centers nationwide, 13 of them were subjected to administrative evaluation. Among the 13 evaluated, 7 of them were located within the Emergency Planning Zone (EPZ: area within 10 km of the NPP).
MIC put the evaluation results into the report “Recommendations Based on Administrative Evaluation and Monitoring of Administration of Nuclear Disaster Prevention (second Stage)” [7] and pointed out that five centers including Fukushima did not have an air-ventilating system that lowers radiation exposure and made a recommendation to correct the situation.
NISA decided to improve the air tightness of the off-site center building and better manage the building entry system; however, they ignored the recommendation by not taking actions like installing an air-filter. NISA did not give sufficient thought to preparing for a large-scale nuclear power disaster.
There were also issues with the NISA staff dispatched to the site. When the earthquake hit, there were seven safety inspectors and one NISA main office staff at Fukushima-1. After the accident, three of the eight moved to the off-site center, and five remained within Fukushima-1. These five, however, moved to the off-site center before dawn on March 12th because the radioactive levels went up in the area.
Later, the local response headquarters was concerned about having no NISA staff on site at Fukushima-1 and decided to dispatch four, who arrived early in the morning of March 13th. These four, however, were not sufficiently active in information gathering such as stepping out of the seismic isolated building to confirm the water injection work. When the reactor building of Unit 3 blew up and the situation of Unit 2 worsened, thinking that they were at risk, they left Fukuhisma-1 at about 17:00 on March 14th without instructions from the local response headquarters.
Another important organization in nuclear regulation was the Nuclear Safety Commission. The commission audited and reviewed safety regulations by NISA and other regulating bodies as a third party and also specified evaluation standards for safety review by the regulating bodies. It also had the task of providing technical support to the central and local governments in case of nuclear power disasters.
The Nuclear Safety Commission, as we pointed out earlier, performed their tasks with their own assumptions that safety with Japanese nuclear facilities was sufficient, the possibility of severe accidents was negligibly small from an engineering perspective, and risks with nuclear reactor facilities were sufficiently small. The severe accident of Fukushima-1 revealed that these ideas were wrong.
3.3.3 Assessment of information management and public announcements
Given its wide impact, the manner in which related organizations supply information to the country and also to the outside world is extremely important, especially with a continuously changing situation such as a nuclear power disaster.
In such a situation, a one-way transfer of administrative and specialist judgments is called risk messaging. In the case of nuclear disasters, highly specialized technical information that is hard to illustrate and data about radioactivity are the subjects of information transfer. In these cases, one-way risk messaging can easily cause confusion and doubts among the population at large. When making information transfer, we shall first understand what it is that people, especially residents in the local area, want to know and then review how people accepted and understood the information.
Public announcements about Fukushima NPP accidents were, at first, made independently by (i) the Chief Cabinet Secretary, (ii) NISA, (iii) local response headquarters, (iv) Fukushima prefecture, and (v) TEPCO; however, on and after March 12th, all announcements were made after approval by the Prime Minister’s Office, and from April 25th on, the government’s and TEPCO’s announcements were coordinated into the same announcements, and press releases were held at the General Headquarters.
The manner in which these organizations made information about the Fukushima-1 NPP accident public caused some confusion in the minds of local residents and the general population; especially the announcements about the spread of radioactivity, its prediction, state of the cores, and the critical situation of Unit 3.
As an example, the Chief Cabinet Secretary and others described radiation effects on the human body using the expression “no immediate effect on the human body.” The phrase “no immediate” created fears among some that “there may be no effect now, but it may cause bad effects in the future” and was an unhelpful expression.
Another serious error by NISA was in replacing the councillor in charge of public announcements who, on March 12th, referred to a possible meltdown during a press conference. The abrupt replacement gave the impression to the public that NISA was concealing something.
Whatever the circumstances were, delays in providing information that required quick announcements, holding back press releases, and giving explanations that were vague and hard to understand interfered with proper judgments by the local residents and caused unnecessary anxiety and confusion.
The fundamental principle of public announcements is to quickly, precisely, and plainly explain the facts. Sticking to this even at a time of emergency is absolutely necessary to help local residents to make their own judgments and avoid causing anxiety and confusion among the people.
3.4 Local government: key responsibilities
3.4.1 Assessing the performance of local government in disaster management
Article 5 of the Nuclear Emergency Preparedness Act required local governments to “take actions necessary for the implementation of measures to prevent nuclear emergency, emergency response measures and measures for restoration from nuclear emergency.” This article means that local governments are expected to, under the instructions and suggestions from the central government, prevent nuclear emergency, take emergency response measures and measures for restoration from nuclear emergency, as the administrative body that actually carry out these missions.
From the accident outbreak on March 11th to the following 12th, as the situations with Fukushima-1 NPP worsened, the central government kept expanding the evacuation and shelter zones while the overall status of the plant remained unclear. Evacuation orders by the central government failed to quickly reach all local governments of the areas and, furthermore, lacked preciseness and proper procedures.
Local governments only had the same level of information that was available from TVs and radios about the nuclear accident and had to lead residents to make the decision to evacuate, find destinations for them, and come up with actual ways of carrying out the evacuation. The situation led to massive confusions in the local area.
The actual records of initial evacuation shows (e.g., in case of the town of Namie) that the functions of the town hall and residents in the immediate vicinity of the plant were relocated to another area far from the plant but within the same town border. On March 15th, however, the town officials were told that the new area was also at risk, and they had to head for the city of Nihonmatsu. The route they took to Nihonmatsu was, however, later revealed to be along the direction of the radiation spread. Also, in the case of the town of Tomioka, residents first took shelter in the village of Kawauchi, but later together with the people of Kawauchi, had to move again to the city of Koriyama.
The evacuation of Futaba hospital
Fukushima prefecture, immediately after the Tohoku Area Pacific Offshore Earthquake, set up the Fukushima Prefecture Disaster Response Headquarters headed by the governor in the large conference room on the third floor of Fukushima Prefecture Hall next to the prefectural government building. After the outbreak of Fukushima-1 NPP accident, the Nuclear Power Group was set up within the headquarters to respond to it. The prefectural disaster prevention headquarters, in the middle of insufficient information and confusion with the unprecedented complex disaster, noted a number of problems. One such problem was the evacuation and rescue of inpatients at Futaba hospital.
Futaba hospital in the town of Ohkuma, next to Fukushima-1 NPP, received the order for evacuation in the early morning of March 12. The 209 patients that could walk on their own and all the hospital staff except the director boarded large chartered buses to evacuate Futaba hospital. At this point, however, about 130 patients confined to their beds, the hospital director, 98 members in the sister nursing house Deauville Futaba, and two of its staff were left at the hospital.
The prefectural disaster response headquarters learned about the people left at Futaba hospital and Deauville Futaba in the morning of March 13th when they received a rescue request from the off-site center. The prefectural disaster response headquarters sent a rescue and transportation request to the Japan Self-Defense Forces.
The Japan Self-Defense Forces rescue team arrived before dawn on March 14th, and started transporting the 98 in Deauville Futaba and 34 of the Futaba Hospital inpatients at around 10:30. After screening, the party arrived at Iwaki Koyo high school 8 h later at about 20:00 on the same day.
The high school expressed concern about accepting such ill patients without medical supplies and doctors. Iwaki Kaisei hospital, however, promised to dispatch doctors to the school, and Iwaki Koyo high school agreed to accept the patients. The patients started to be carried into the gym at about 21:30 on the same day, and eight of them were found to have passed away during the transportation.
At about 11:00 on March 15th, while radioactivity was high, the Japan Self-Defense Force started transporting the 47 left in Futaba hospital, and another Japan Self-Defense Force team rescued 7 at about 11:30. These 54 patients, after screening, headed toward Fukushima Medical University Hospital which was unable to admit them. At about 01:00 on March 16th, they arrived at Date Fureai Center. Two patients died during the transportation of this group.
Lastly, at about 00:30 on March 16th, rescue of the 35 that had remained in Futaba hospital started, but again 5 of them passed away during transportation.
This tragedy was caused by the following circumstances:
Firstly, Fukushima prefecture’s disaster prevention plans had teams for resident evacuation, safety (responsible for arranging evacuation vehicles), and rescue (responsible for counting the number of remaining patients and securing destination hospitals). However, actual members of the teams had multiple assignments, and there was no managing group for overall control. This meant that there was no clear idea of where the evacuees were located until March 13th.
Secondly, the prefectural emergency response headquarters had learned that most of the inpatients at Futaba hospital were confined to bed. However, they had not shared that information within the headquarters. Then the transportation arrangement on March 14th supplied vehicles not suited for moving patients confined to bed.
Thirdly, the prefectural department in charge had already arranged for destination hospitals, aside from the prefectural disaster response headquarters, but the information had not been given to headquarters, and the transportation team ended up in a high school gym in a remote location.
Lastly, on the evening of March 14th, the director of Futaba hospital took shelter with policemen in a separate location to wait for the Self-Defense Force team to arrive. The information was relayed to the prefectural emergency response headquarters, but was not shared within the headquarters. The Self-Defense Force team failed to meet the director and policemen on March 15th, and the team of the second rescue mission that day never knew about the 35 remaining patients, who had to wait past midnight for rescue.
In all, the Fukushima emergency response headquarters had initial problems in clarifying responsibility assignments for each group and sharing information. The shortcomings led to insufficient administration in preventing the spread of the disaster.
Assessing the accident response by the prefecture
The Fukushima prefectural government made inadequate moves in distributing stable iodine tablets.
Stable iodine, when taken before exposure to radiation, prevents radioactive iodine accumulation in the thyroid gland, even if the material enters the body. The Nuclear Safety Commission compiled “About preparatory administration of stable iodine at times of nuclear disasters” [8], in which it wrote, “The disaster response headquarters shall make judgments for preparatory administration of stable iodine, in addition to preventive measures of taking shelter and evacuation” [8] and local towns that surround Fukushima-1 and -2 had prepared stable iodine tablets before the accident.
The town of Miharu, late at night on March 14, decided to distribute and administer stable iodine tablets to prepare the residents against radiation exposure. At around 13:00 on March 15th, the town made an announcement over the wireless town loudspeaker system and, under the supervision of the town pharmacist, distributed stable iodine tablets to about 95% of the residents. Learning about this distribution, a staff member at Fukushima Health and Welfare Department, in the late afternoon on the same day, ordered the town to stop the distribution and recall the tablets because the central government had not instructed the administration at that time. Miharu ignored the order and did not recall the tablets.
The administration of stable iodine tablets is formally subject to a decision by the disaster response headquarters of the central government; however, the move by Miharu was to protect the health of the local residents. Opposition by the prefecture staff for receiving instructions from the central government was inappropriate.
As in the preceding examples, the local government made a number of misjudgments as a result of confusion and lack of information (see Ref. [24] for comments on the local government response).
3.5 Conclusions: key lessons and improvements needed
A Nobel Prize economist, Herbert Simon, explained that humans have limits to rational behavior and named the concept “limited rationality” in his book Administrative Behavior: A Study of Decision-Making Processes in Administrative Organizations [9]. In other words, Simon pointed out that there is a limit to the intellect of humans, and we cannot predict all problems that will happen in the future. We can never overcome our limitations, and learning from troubles and accidents that did take place helps us expand our views and ranges of recognition.
In January 1995, the Great Hanshin-Awaji Earthquake occurred, killing thousands of people; this occurred 47 years after the Fukui Earthquake in 1948 that took 3769 lives. The Tomiichi Murayama Cabinet at the time of the 1995 quake made a number of mistakes.
Sixteen years later, with the Great East Japan Earthquake, the Self-Defense Force quickly entered the picture after learning from the Great Hanshin-Awaji Earthquake. The earthquake and tsunami with the Great East Japan Earthquake completely destroyed many lifelines of electricity, gas, and water; however, a number of business organizations made great efforts in helping the region, another lesson learned from the Great Hanshin-Awaji Earthquake.
The Fukushima-1 NPP accident, on the other hand, faced simultaneous problems with three of its nuclear reactors and progress with one nuclear reactor affected actions and responses with neighboring reactors. Up to that point, severe accident management in Japan never had to deal with severe simultaneous accidents with multiple nuclear reactors. No preparation had been made for such an event, and the actual responses gave rise to a number of problems and questions.
The International Nuclear and Radiological Event Scale (INES) ranks problems with nuclear power facilities in terms of safety in eight levels of 0-7. Levels 1 through 3 are categorized as incidents, and 4-7, accidents. An incident is an event that threatens or possibly threatens safety. The distinction between an incident and an accident is in the size of the effect. When the effect reaches outside of the facility and at least one person dies from the effect of radiation, the event is an accident.
Up to the point of Fukushima-1 NPP accident, the most severe incident in Japan was the 1999 Tokai JCO criticality accident at its nuclear fuel processing plant (two workers died from fatal radiation exposure). The second worst was at the Power Reactor and Nuclear Fuel Development Corporation (later merged into Japan Atomic Energy Agency in 2005) fire and explosion accident in 1997 at its Tokai asphalt caking facilities (37 workers were exposed to radiation). The former was evaluated at Level 4, and the latter at Level 3. Both accidents took place in nuclear power-related facilities and not NPPs. NPPs in Japan had only experienced Level 2 or less severe troubles before, not to mention none that released a large amount of radioactivity.
The Three Mile Island and Chernobyl accidents showed that severe accidents that exceed the design standards could happen with NPPs. The Fukushima-1 accident reminded us of the importance of learning from past accidents.
