Impact of Management Decisions on
Accidents: Fukushima (Daiichi Accident), Challenger
and Macondo Oil Well Explosion
By
Anthony J Spurgin
Independent Consultant
San Diego
11/14/2012
IEEE Section & Reliability Meeting
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Introduction
• The presentation will discuss an important aspect in
the underlying causes of accidents, namely the role of
management decision-making
• Here I want to consider the role of management in the
process of accident initiation and progression
• Accidents are often perceived as random events
involving natural events or caused by the actions of
humans, so called human errors
• Management decisions are considered to be the
greatest contribution to both accident initiation and
faulty recovery
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All Organization are:
Shaped by Accidents-Continued
• Industry has always reacted
to accidents
• Changes have occurred in
organizations
• Organizations have
changed:
– Their outlooks, Mgmt.
organization and functions,
training/maintenance
• Regulators have changed
• INPO and WANO have been
formed in the Nuclear
Business
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Areas of Influenced
by Decisions
1. Prior to the accident
2. During the accident
3. Post accident - recovery
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Prior to Accident: Influential Decisions
1. Selection of Specific Plant Design
2. Selection and training of staff
3. Approach to accidents, including design of
procedures; normal, abnormal, emergency
and post accident procedures
4. Specifics of man-machine interfaces
5. Failure to deeply consider possible accidents
on defense capabilities of plant (not identical
to why one selects a plant because of
economic reasons)
6. Consideration of impact of accidents on the
capabilities of internal and external personnel
to recover a plant (terminate/mitigate)
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Decisions;
During Accident
1. Formation of Response teams
2. Prior development and test of
response procedures
3. Training of teams
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Decisions;
Post-Accident recovery
1. Availability of well trained rescue
teams
2. Understanding of how accidents can
affect accident working conditions
3. Rapid availability of support
materials and tools: generators, etc
4. Flexible emergency procedures
capable of being applied to a variety
circumstances
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Illustration of Findings:
Selection of accidents and situations
1. Daiichi accident, Japan
2. Challenger Accident, NASA
3. BP Macondo accident
4. Sandy, N-E Coast Weather
Time is short so these will not be
covered
1. Three Mile Island Accident
2. LA rail Accident
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Fukushima, Daiichi
Accident and Impact
1. These are my comments on the accident and are
not the position of IEEE or anyone else
2. Clearly this accident has already had an effect on
the Nuclear Industry world wide
3. Japan and some other countries have taken
actions to shutdown or phase-out NPPs. These
actions, I think, are basically unscientific,
emotional and/or political inspired
4. Lessons to be drawn from the accident
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Fukushima Accident and Impact : Review
• Some damage from the earthquake, but real damage caused by the
resulting tsunami
• Tepco (plant owners) completely responsible for their inaction in
protecting NPPs : this resulted in the future cost of the NPPs being
written-off and resulting cleanup due to core partial melts (like TMI
#2)
• Electrical distribution within plants shorted due to ingress of water,
even if loss of diesels had not occurred, the plant personnel could
not have quickly connected pumps, valves, etc.
• Plant personnel had not established and practiced procedures to
deal with the issue (Tepco Mgmt deficiency, see earlier item)
• Plant supervisor tried to ad hoc actions to rescue the NPPs, too
little too late
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Fukushima Accident and Impact , continued
• Water Levels: Tsunami related
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Cross Section of a Fukushima NPP
showing plant and key water levels
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Fukushima Accident and Impact , continued
1.
Plant personnel tried to deal with the situation as
best they could, but even as they got things
moving, but often the effects of the accident
negated their actions
2. Hydrogen releases following core damage were
not dealt with effectively
3. Resulting hydrogen led to explosions, which
caused injuries, blocked paths and destroyed
cables, trucks,
4. The crews had problems with valves, poor access
and bad working conditions, radiation
5. Eventually they were able to inject both clean
and sea water to cover the remains of the cores
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Direct Lessons from
the Fukushima Accident
1. Failure to prevent the consequences of the Tsunami:
need to re-evaluate external events and
management decisions –act promptly to rectify
2. Diesels were placed too low vs a vs the high water
level: increase height margins or add protective
methods
3. Electrical systems, switch gear, etc. located in
basement of Reactor buildings, too vulnerable to
floods: need for better protection, consider all
pathways!
4. Poor emergency planning, training and positioning of
support equipment : review, update and train
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Fukushima Accident and Impact:
lessons for all
1.
2.
3.
4.
5.
6.
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Need to review design bases on a regular period to ensure
assessment of external and internal events has not changed and
then act promptly to correct situation
Be aware that "Black-out" is not just the diesels and batteries, but
includes power and instrumentation distribution systems
Develop emergency procedures, somewhat like the symptom-based
EOPs, that take into account unknown accident conditions, that can
affect the plant and ability of personnel to prevent core damage
Practice these procedures and use of emergency equipment on a
regular basis, more than once a year
Be aware of the cost-benefit of safety upgrades relative to the costs
related to the effects of core damage, loss of plant, loss of
generation and long clean-up follow a core-damage accident
Need for political bodies to realize that effects of radiation releases
maybe significantly less than the direct effects of earthquakes and
tsunamis on the public
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Macondo Well Accident: British Petroleum
Decisions
•
•
•
•
•
•
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BP underestimated the issues with the local
management relative to taking actions not in
the real interest of BP as a whole. Decisions
made to save small amounts of money, but
risking much more. Lack of perspective on
behalf local management
BP main management failed to have a risk study
to identify the consequences of a failure of the
BOP valve isolation system. Superficial
understanding of common cause issues led to a
locally reliable system that failed to perform
Local BP management did not have an effective
quality control program
Local rig members seemed to be not as well
trained in safety aspects as they should be
BP analysis of the possibility of stopping the leak
along with others was too optimistic leading to a
failure by BP management to state the correct
time to fix
US Government fixated on BP’s responsibility in
the case of the leak and failed to see what their
proper role was. They acted much too late and
even then did not fully commit both US and
other resources. In fact they seemed to act
against the interests of the citizens living the
Gulf regions
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Challenger Accident: Management
and Engineering Decisions
•
•
•
•
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NASA top management wanted to launch
the Challenger on time and did not wish
to hear any engineering ‘overly
conservative engineering opinions’,
because of implied political pressure.
Interesting the pressure seemed to be self
imposed by NASA, since no trace of a
request from Reagan has been located.
NASA should have investigated the “O”
ring near failures earlier. This was a failure
on the part of NASA and Morton Thiokol.
There are suggestions this was a failure of
personnel at lower levels to forward
information on the problems with the
design of the “O” ring joint
NASA had a launch review procedure, the
launch directors should have followed a
more conservative process based upon
engineering advice
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Sandy and similar storms:
Comments & Decisions
• Storms and floods occur on regular basis
• Specific lessons have been learned and
forgotten
• The Dutch invented the polder system,
including wind driven pumps, many years ago
• In more times the British have introduced the
Thames barrage system to protect London
from North sea storm surges and high water
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Storms in later part of 20th Century, source: Wikipedia
Season
Storm
Category: Peak intensity, Intensity at landfall, Date
1938 New England Hurricane of 1938 Category 5 Category 3 September 21, 1938
1944 Great Atlantic Hurricane Category 4 Category 1 September 15, 1944
1952 Hurricane Able Category 2 Tropical Depression September 1, 1952
1954 Hurricane Carol Category 3 Category 3 August 31, 1954
1954 Hurricane Edna Category 3 Category 1 September 11, 1954
1955 Hurricane Diane Category 3 Tropical Storm August 18–19, 1955
1959 Hurricane Cindy Category 1 Tropical Storm July 11, 1959
1960 Hurricane Donna Category 5 Category 2 September 12, 1960
1961 Hurricane Esther Category 4 Tropical Storm September 26, 1961
1966 Hurricane Alma Category 3 Extr. Storm June 13, 1966
1971 Tropical Storm Doria Tropical Storm Tropical storm August 29, 1971
1972 Hurricane Agnes Category 1 Tropical Storm June 22, 1972
1972 Tropical Storm Carrie Tropical Storm Tropical Storm September 3, 1972
1973 Subtropical Storm Alfa Tropical Storm Subtropical Storm July 30, 1973
1976 Hurricane Belle Category 3 Tropical Storm August 10, 1976
1985 Tropical Storm Henri Tropical Storm Tropical Depression September 23, 1985
1985 Hurricane Gloria Category 4 Category 1 September 27, 1985
1988 Tropical Storm Chris Tropical Storm Tropical Depression August 29, 1988
1991 Hurricane Bob Category 3 Category 2 August 19, 1991
1996 Hurricane Bertha Category 3 Tropical Storm July 13, 1996
1999 Hurricane Floyd Category 4 Tropical Storm September 16–17, 1999
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Storms in North-East
1. Mostly in Fall
2. 21 over 91 years (20% probability)
3. Ranged from Tropical depression to
category 5 storm
4. Affected N-E areas from New Jersey to
Maine
5. Caused flooding to wind caused destruction
6. Predicable
7. Not due to Global weather change (not a
new phenomena)
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Sandy: Observations and Comments related
to Organizational Deficiencies
1.
2.
3.
4.
5.
6.
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Failure to learn from past storms and equivalent
accidents
Failure of to understand limitations of emergency
electric power for hospitals, see Daiichi accident (need
to protect power supplies from flooding)
Inadequate establishment and training of teams
Need to develop and test of response procedures
Inadequate availability of supplies to support civilians
and rescuers
Failure to foresee limitations of water barriers and
consequences for citizens, either build defenses or
limit areas to building near coast
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Recommendations for decision-makers
1.
2.
3.
4.
5.
6.
7.
Failure to prevent the consequences of the weather induced effects:
need to re-evaluate external events and management decisions –act
promptly to rectify
Emergency power systems were placed too low vs a vs the high water
level: increase height margins or add protective methods
Electrical systems, switch gear, etc. located in basement of buildings, too
vulnerable to floods: need for better protection, consider all pathways!
Poor emergency planning, training and positioning of support equipment
: review, update and train
Consider possible design solutions from other places, time and people,
consider barriers and other solutions: review options and make better
decisions
Top managers often lack basic skills and training: Acquire better training
and/or rely on your support team
Support team: Have more faith in your advice
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